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ARTIFICIAL  ANJ:STHESIA. 


^  Manual 


ANESTHETIC  AGENTS 

AND   THEIR 

EMPLOYMEJ^T  IN  THE  TEEATMENT 
OF  DISEASE. 

BY 

LAUKENCE  TURNBULL,  M.D.,  PH.G., 

Aural  Surgeon  to  the  JeflFerson  Medical  College  Hospital,  Philadelphia,  Late  Honorary- 
President  of  the  Otological  Subsection  of  the  British  Medical  Association,  Etc. 

THIRD  EDITION.     REVISED  AND  ENLARGED. 


WITH    ILLUSTRATIO 


PHILADELPHIA: 

P.  BLAKISTON,  SON  &  CO., 

1012  Walnut  Street. 

1890. 


/U~.<^c)  '  oM/-^' 


^•2-^-2 


Entered  according  to  Act  of  Congress,  in  the  year  1890,  by 

LAURENCE  TUIINBULL,  M.D. 

In  the  office  of  the  Libraiian  of  Congress.    All  rights  reserved. 


A 


In  1847,  Oliver  Wendell  Holmes  created  the  words  artificial 
ansestliesia,  and  wrote :  "  Nature  herself  is  working  out  the  primal 
curse  which  doomed  the  tenderest  of  her  creatures  to  the  sharpest 
of  her  trials ;  but  the  fierce  extremity  of  suff'ering  has  been  steeped 
in  the  waters  of  forgetfulness,  and  the  deepest  furrow  in  the  knotted 
brow  of  agony  has  been  smoothed  forever." 


"  If  America  had  contributed  nothing  more  to  the  stock  of  human 
happiness  than  anaesthetics,  the  world  would  owe  her  an  everlasting 
debt  of  gratitude." — The  late  Professor  Samuel  D.  Gross. 


PREFACE  TO  THE  THIRD  EDITION. 


The  Author  has  endeavored,  in  this  the  Third  Edition  of 
hia  Manual,  to  make  a  thorough  revision  of  the  whole  subject 
of  Artificial  Anaesthesia.  The  time,  he  thinks  has -arrived, 
after  forty-five  years'  (1844-1889)  trials,  of  these  most  wonder- 
ful and  beneficent  agents,  by  the  medical  and  surgical  profes- 
sion, to  have  some  definite  and  positive'  opinion,  as  to  their 
relative  safety  in  the  various  operations,  and  the  risks  and  re- 
sponsibility attending  their  use,  in  the  healthy  and  diseased 
conditions  of  the  human  body. 

By  a  careful  and  conscientious  study  of  each  agent,  its  natu- 
ral and  physiological  characteristics,  and  peculiarities,  each 
and  every  medical  man  can,  and  should,  select  the  one,  which  he 
knows  and  feels  will  be  just  suitable  in  the  peculiar  case  on 
hand. 

By  the  discovery  of  true  and  positive  local  anaesthetics,  and 
by  their  careful  use  in  all  minor  operations  in  surgery,  much 
of  the  risk  to  life  is  prevented 

All  hopes  have  passed  away — for  the  time  being  at  least — 
that  any  one  of  the  systemic  anaesthetics,  is  absolutely  free 
from  risk  to  life,  for  we  now  know,  full  well,  that  anaesthesia 
carried  to  the  effect  of  a  profound  impression  on  the  human 
subject,  sufficient  for  a  capital  operation,  is  but  a  step  from 
death.. 

It  has  been  proven  in  numerous  cases  that  it  requires  but  a 
slight  excess  in  the  quantity   employed,  perhaps  a  lack   of 

V 


PREFACE   TO   THE   THIRD   EDITION. 

atmospheric  air,  great  fear  or  dread  concerning  operation  or 
anajsthetic,  the  faulty  or  non-action  of  a  deranged  kidney,  or 
heart,  perchance  a  careless  administration — and  the  patient  is 
dead.  In  making  the  additions  and  alterations  to  our  Manual, 
necessary  at  the  present  day,  many  changes  have  led  to  an 
increase  in  the  size  of  this  book. 

We  would  advise  all  who  are  obliged  to  use  anaesthetics,  to 
memorize  the  prominent  points,  so  that  when  a  case  of  emer- 
gency arises,  it  will  not  be  necessary  to  seek  information  in  the 
book,  and  all  unnecessary  haste,  worry,  and  confusion,  would 
be  avoided,  knowing  just  what  to  do  for  the  best  interest  of  the 
suffering  patient,  nigh  unto  death. 

The  indiscriminate  and  careless  administration  of  the  most 
powerful  anaesthetic  agents,  is  the  crying  evil  of  the  present  day, 
and  we  feel  sure  that  in  the  near  future,  legislative  action  will 
be  taken,  to  prevent,  under  heavy  penalty,  any  one  from  giving 
an  ansesthetic,  unless  he  or  she  be  provided  with  a  certi6cate  that 
they  fully  understand  the  chemical,  physiological,  and  medical 
agents  they  are  about  to  employ,  and  have  had  experience  in 
their  use,  under  a  competent  surgeon,  and  have  been  subjected 
to  a  careful  examination  of  the  knowledge  they  have  thus 
acquired. 

Human  life  is  too  valuable,  at  the  present  day,  to  be  de- 
stroyed by  incompetent  administrators  of  such  beneficent,  yet 
death-giving  agents. 

The  following  is  the  most  recent  warning  on  this  subject : 
"The  announcement  that  the  anaesthetist  in  a  fatal  case  of 
chloroform  narcosis,  at  Sidney,  Australia,  has  been  found  guilty 
and  sentenced  to  pay  two  hundred  pounds  damages,  on  the 
ground  that  the  antesthetic  had  been  improperly  administered, 
comes  with  rather  a  startling  effect.  While  no  conscientious 
man,  be  he  lay  or  medical,  will  dispute  the  justice  of  such  a 
vi 


PEEFACE    TO    THE   THIRD    EDITION. 

verdict,  when  negligence  is  clearly  proven,  difficulties  arise 
when  such  matters  are  adjudicated  upon  by  a  jury  of  persons, 
who,  whatever  their  intelligence,  are  profoundly  ignorant  of 
what  constitutes  negligence  in  this  respect. 

"It  would  be  but  a  step  further  for  juries  to  enforce  the  opinion, 
which  has  been  gaining  ground,  as  to  the  advisability  of  giving 
chloroform  at  all,  unless  specially  indicated.  Still,  this  is  a 
matter  well  within  the  discretion  of  the  medical  man,  and  it 
would  be  impolitic,  as  well  as  unjust,  to  fetter  the  exercise  of 
that  discretion  by  a  fear  of  legal  consequences. 

"  Short  of  negligence,  amounting  to  a  criminal  act,  we  cannot 
conceive  of  such  a  verdict  in  this  country  (England),  and  we 
sincerely  hope  that  the  example  will  not  be  the  means  of  im- 
posing an  additional  horror  to  the  life  of  medical  men  who  have 
enough  to  attend  to,  in  guarding  themselves  against  vexatious 
actions  for  having  signed  lunacy  certificates,  and  in  avoiding 
the  wiles  of  designing  women,  with  an  eye  to  blackmail."  * 

The  subject  of  the  administrations  of  ether  per  rectum,  still 
claims  some  interest.  The  author  retains  part  of  the  literature  on 
that  subject,  modifying,  and  giving  the  most  recent  cases  which 
have  been  reported.  The  application  of  such  powerful  agents 
by  the  rectum,  offers  many  objections  to  general  use,  although 
in  some  rare  cases,  it  can  be  resorted  to  with  success  when 
cocaine  is  neither  admissible,  nor  sufficiently  powerful. 

In  this  edition  of  the  work,  the  author  has  retained  the 
description,  and  illustrations  of  the  various  inhalers.  Some  are 
not  recommended  as  highly  as  others,  but  all  have  certain  mer- 
its, and  demerits;  still,  this  department  has  been  found  of 
practical  use,  in  the  saving  of  time,  to  those  who  are  not  famil- 
iar with  the  various  modifications  made,  or  work  performed. 
The  author  desires  to  return  thanks  to  Dr.  Buxton  for  his  kind- 

*  Dr.  E.  Hart,  British  Medical  Journal. 


PREFACE   TO   THE   THIRD    EDITION. 

ness  in  allowing  his  publishers  to  furnish  several  illustrations 
of  instruments,  and  one  of  tracings;  the  former  being  in  con- 
stant use,  and  highly  thought  of  by  the  physicians,  surgeons 
and  dentists  of  Great  Britain.  Here,  also,  he  makes  a  general 
acknowledgment  of  having  freely  availed  himself  of  Dr.  Bux- 
ton's labor  in  original  communications  sent  to  him,  knowing 
how  much  they  will  be  appreciated  by  his  professional  breth- 
ren in  this  country,  he  "  being  Administrator  of  Anaesthetics 
in  several  Loudon  hospitals." 

The  author  desires  to  acknowledge  many  courtesies  at  the 
hands  of  several  members  of  the  medical  profession. 

He  is  also  indebted  to  the  liberality  of  the  S.  S.White  Dental 
Manufacturing  Co.  of  this  city,  for  the  use  of  valuable  cuts  of 
instruments  and  apparatus.  Also  to  Parke,  Davis  &  Co., 
Detroit,  Michigan. 

The  author's  sole  object  has  been  to  make  this  work  a  scienti- 
fic, yet  practical,  and  safe  guide,  no  labor  nor  expense  having 
been  spared  in  attempting  to  accomplish  this  object. 

1502  WALNUT  STKEET,  PHILADELPHIA, 
December,  1889. 


PREFACE  TO  THE  8E0OND  EDITIOA^, 


The  rapid  sale  of  a  large  edition  of  thia  work  in  the  short 
period  of  one  year,  shows  the  appreciation  with  which  it  has 
been  received  by  the  medical  and  dental  press  and  professions. 
Its  success  has  induced  the  author  to  revise  the  subject-matter 
and  rewrite  several  of  the  articles.  To  make  the  volume  more 
worthy  of  the  favor  of  the  profession,  a  number  of  new  and 
original  experiments  have  been  made ;  especially  with  hydro- 
bromic  ether.  The  boiling  points  and  relative  time  of  evapo- 
ration of  the  several  agents  employed  in  mixed  anaesthetics, 
and  the  best  proportion  in  which  ether,  alcohol,  and  chloro- 
form should  be  united,  have  been  determined ;  also  a  continua- 
tion of  the  experiments  on  the  action  of  anse&thetics  on  the 
blood,  the  use  of  the  spectroscope  in  relation  to  anaesthetics, 
more  especially  nitrous  oxide. 

In  this  second  edition  there  will  be  found  many  more  prac- 
tical suggestions  as  to  the  employment  of  anaesthetics  that  are 
safe,  and  the  rules  for  their  adoption  or  reasons  for  the  rejection 
of  some  of  them  in  different  cases,  grouped,  and  made  conve- 
nient, so  that  the  student  can  memorize  them,  and  be  fully 
prepared  for  any  emergency.  As  has  been  well  observed  in  a 
review  of  this  work  by  the  distinguished  editor  of  the  Dental 
Cosmos,  "When  trouble  comes  to  a  patient  from  any  cause 
during  the  anaesthetic  state,  it  is  not  a  good  time  to  hunt  up 
information." 

The  new  table  of  deaths  from  chloroform  which  has  been 
added,  and  in  the  preparation  of  which  much  time  and  labor 
has  been  expended,  will  be  found  of  special  interest  and  vital 
importance  in  regard  to  the  sex,  age,  character  of  operation. 

3 


4  PREFACE   TO    THE   SECOND    EDITION. 

time  at  which,  the  patient  died,  quantity  of  chloroform  used, 
and  form  of  apparatus  employed,  general  condition  of  patient, 
prominent  symptoms  of  chloroform-poisoning,  causes  of  death 
and  post-mortem  appearances.  A  new  ether  inhaler  has  heen 
described  and  illustrated,  which  has  been,  and  is  now,  employed 
in  the  clinical  service  of  Jefferson  College  Hospital. 

A  bibliography  published  in  the  first  edition  has  been 
omitted,  but  additional  old  or  new  works  which  were  not  then 
introduced,  or  cannot  be  found  mentioned  in  the  body  of  this 
work,  have  been  printed  for  reference. 

A  historical  sketch  of  the  discovery  of  anaesthesia  at  the  end 
of  the  previous  edition  has  also  been  omitted,  as  more  epace 
has  been  devoted  to  the  subject  in  our  introduction,  but  full 
references  to  all  the  authorities  on  the  subject  have  been  given. 

There  has  been  introduced  a  notice  of  the  metric  system  in 
accordance  with  the  recommendations  of  the  "American  Medi- 
cal Association"  at  its  last  meeting,  at  Atlanta,  in  May,  1879; 
also  a  table  of  the  Centigrade,  and  Fahrenheit  thermometric 
scales.  More  space  has  likewise  been  assigned  to  the  physio- 
logical and  therapeutic  action  of  anaesthetics  in  disease.  In 
most  of  the  instances  where  a  remedy  has  been  recommended, 
the  authority  has  been  quoted,  or  we  have  tested  its  therapeutic 
value  in  an  extensive  private  practice,  or  in  the  daily  clinics  of 
two  large  public  institutions. 

It  was  found  impossible  to  acknowledge,  in  every  instance, 
the  source  from  which  all  contained  facts  have  been  obtained, 
but  in  the  majority  of  instances  we  have  endeavored  to  give 
credit  to  every  original  worker  in  the  field  of  progress.  The 
Author  desires  to  acknowledge  many  courtesies  at  the  hands  of 
several  eminent  members  of  the  profession;  but  he  is  especially 
indebted  to  his  son.  Dr.  Charles  S.  Turnbull,  and  others. 

1502  WALNUT  STREET, 
June,  1879. 


PKEFACE  TO  THE  FIRST  EDITION. 


This  little  work  was  originally  written  by  the  Author  as  a 
report  for  a  medical  society,  and  was  subsequently  extended 
to  its  present  form  to  supply  a  want  that  evidently  exists  at 
the  present  day,  for  a  convenient  hand-book  on  the  adminis- 
tration of  the  various  anaesthetics,  that  the  practitioner  of 
medicine  or  dentistry  can  consult,  to  enable  him  to  decide 
which  one  he  can  best  employ.  Many  valuable  books  have, 
unquestionably,  beeu  written  on  the  subject  of  anaesthetics, 
but  as  far  as  the  writer's  observations  extend,  none  of  a  practi- 
cal character  have  appeared  within  the  last  few  years.  Much 
useful  matter  in  relation  to  sulphuric  ether,  "nitrous  oxide,'' 
and  chloroform,  employed  as  ansesthetics,  has  accumulated 
within  this  period,  but  this  valuable  information  is  contained 
in  various  monographs,  journals,  etc.,  where,  associated  with 
what  is  extraneous,  it  is  unprofitable  to  the  busy  practitioner. 

The  object  of  this  work  raay  be  stated  to  be: — 

First.  To  give  in  as  concise  a  manner  as  possible  a  descrip- 
tion of  the  most  available  agents  that  may  be  successfully  and 
safely  employed  as  ansesthetics. 

■  Second.  To  present  the  chief  chemical  tests  of  the  purity  of 
each  substance  considered,  with  its  composition,  physical  char- 
acters, and  medical  properties. 

Third.  To  exhibit  the  best  methods  of  administering  the 
various  ansesthetics,  to  give  careful  directions,  and  to  state  the 
precautions  to  be  taken  to  avoid  risk  to  the  life  of  the  patient. 

5 


6  PREFACE   TO   THE   FIRST   EDITION. 

Fourth.  To  note  the  personal  experience  of  the  author,  his 
assistants  and  friends,  with  anaesthetics  and  the  various  forms 
of  inhalers  in  use,  with  a  selection  of  the  most  approved,  not 
withholding,  however,  the  objections,  but  noting  the  experi- 
ments of  other  reliable  investigators. 

Fifth.  To  compare  the  relative  mortality  from  all  the  anaes- 
thetics now  employed,  endeavoring  to  assist  the  reader  in 
forming  a  fair  and  candid  opinion  of  this  most  important 
subject,  which  is  now,  and  has  for  so  long  a  period,  occupied 
the  attention  of  the  public  as  well  as  of  the  medical  profession. 

To  conclude  are  added  practical  hints  on  Local  Anaesthesia, 
the  use  of  the  various  Anaesthetics  in  the  practice  of  medicine; 
the  Medico-Legal  Nature  and  Importance  of  Anaesthetics,  with 
a  brief  History  of  the  Discovery  of  Artificial  Anaesthesia. 

1502  WALNUT  STREET, 
March,  1878. 


TABLE   OF   CONTENTS. 


PART    FIRST. 

CHAPTEE  I. 

Page. 

History  of  Ancient  and  Modern  Ansesthesia  and  Anaesthetics  .  .    17-25 
CHAPrER  II. 

The  True  Value  of  Anaesthetics — Theories  of  the  Manner  in 
which  Anaesthetics  Produce  their  Effects — Local  Anaesthesia 
and  Anaesthetics  — M.  Oscar  Liebreich's  Communication  on 
Substances  which  Cause  Local  Anaesthesia  .   .......      2529 

CHAPTER  III. 
Coca  Plant,  Leaves,  Preparations  Wine  of  Coca,  made  from  the 
Leaves,  also  from  the  Cocaine — Therapeutical  Uses  of  Coca 
Leaves — Cocaine  and  its  Salts,  Discovered  by  "  Gaedeke," 
but  thoroughly  studied  by  "Niemann" — Physical  and 
Chemical  Properties  of  Cocaine — Chemical  Tests — Decom- 
position— Cocaine  and  its  Impurities — The  Instability  of 
Cocaine,  Further  Tests — Amount  of  Cocaine  Employed,  and 
its  Salts  made  and  sold  in  the  United  States 30-35 

CHAPTER  IV. 
Experiments  with  Cocaine  on  Animals  and  Man — The  Physio- 
logical Action  of  Cocaine  upon  the  Animal  System,  more 
especially  upon  Dogs,  by  "Mosso,  of  Turin,"  Professors 
Reichert  and  Hare,  of  the  University  of  Pennsylvania,  and 
the  author;  also  by  Von  Anrep — Dr.  Buxton,  of  London,  on 
the  Heart  of  the  Frog — On  the  Action  of  Cocaine  on  the  Eye, 
by  Dr.  Karl  Koller,  of  Vienna — The  Dose  of  the  Hydro- 
chlorate  of  Cocaine — On  the  Hypodermic  Employment  of 
the  Hydrochlorate  of  Cocaine — Strength  of  Solutions,  pre- 
venting Formation  of  Fungi— Fatal  Dose  of  Hydrochlorate 
of  Cocaine — Dr.  Hammond's  Experiments  with  large  Doses 

7 


8  '  TAP.l.E   OF    (H)XTENTS. 

Paok. 
— Fifteen  Deductions  as  to  the  Action  of  Cocaine,  by  the 

Author 36-43 

CHAPTER  V. 

Cocaine  Inebriation  and  Habit — Experience  and  Treatment  by 
T.  D.  Crotliers,  M.D. — Personal  Experience  of  Dr.  Bos- 
worth,  of  New  York,  and  Dr.  Frank  W.  Iling— Opinion  of 
Dr.  Osier— J.  B.  Mattison,  of  Brooklyn,  N.Y.— Treatment  of 
Nervous  Symptoms  from  Cocaine — Further  Treatment  of 
Cases  of  Poisoning  from  Cocaine— The  Toxic  Action  of  Co- 
caine in  certain  Operations — Death  from  Cocaine  in  a  Lady 
with  Tuberculous  Ulcer  of  the  Uterus — Cases  of  Death 
from  Cocaine  reported  by  Dr.  W.  H.  Long,  U.  S.  Marine 
Hospital  Service;  Dr.  F.  M.  Thomas,  of  Leonardsville, 
Kan. ;  Dr.  Knabe,  of  Berlin ;  Dr.  Abadie,  of  Paris  ;  Dr. 
J.  Henry  C.  Simes,  of  Philadelphia — Zamibianchi  and  Men- 
talti — Comments  on  the  Cases  by  the  Author — Morbid 
Changes  in  Acute  and  Chronic  Poisoning  of  Dogs  by  Co- 
caine        44-60 

CHAPTER  VI. 

Cocaine  in  Surgery,  Obstetrics  and  Gynecology — Cocaine  An- 
sesthesia  in  Femoral  Supra-condyloid  Osteotomy  and  Exci- 
sion of  the  Hip-Joint — Cocaine  in  Minor  and  Major  Sur- 
gery— "  The  Status  of  Cocaine  in  Surgery,"  by  Dr.  Wyeth, 
of  New  York — Minute  Directions  in  Various  Surgical  Op- 
erations— Cocaine  in  Hemorrhoids,  Fissures,  Fistiilas  and 
Diseases  of  the  Anus — Cocaine  in  Operations  on  the  Blad- 
der and  Urethra — Circumcision  under  Cocaine  Anajsthesia 
— Cocaine  in  Obstetrics  and  Gynaecology — Cocaine  in  Dys- 
menorrhoea — Cocaine  in  Vaginismus— Means  to  Prevent 
the  Injurious  Effects  from  Cocaine  in  Local  Anaesthesia,  in 
Dentistry  and  Minor  Surgery  by  the  use  of  Phenic  Acid  — 
Cocaine  in  Intra-Nasai  Surgery 60-75 

CHAPTER  VII. 

Therapeutics  of  Cocaine — Gastritis  Produced  by  Poisoning 
Treated  by  Cocaine — The  Treatment  of  Affections  of  the 
Stomach — Uncontrollable  Vomiting — Lavage  or  Gavage — 
Boulimie,  or  Insatiable  Hunger — Tetanus  Treated  by  Mor- 
phia and  Cocaine — Cocaine  in  Skin  Diseases  — Chilblains, 
Burns,  Anal  or  Vulval  Pruriency,  or  Painful  Herpes,  and 
Cracked  Nipples 75-79 


TABLE    OF    CONTENTS.  9 

Page. 
CHAPTER  VIII. 

Cocaine  in  Acute  Catarrh,  Coryza,  or  Cold  in  the  Head— Co- 
caine in  Hay  Fever — Cocaine  with  Resorcin,  in  Whooping- 
Cough,  Pharyngitis,  Laryngeal  Tuberculosis,  Paroxysmal 

Sneezing,  Asthma 79-83 

CHAPTER  IX. 

Cocaine  in  Antiseptic  Solutions  for  the  Eye — Drs.  Keyser  and 
Strawbridge  have  no  more  Injurious  Results,  owing  to  the 
use  of  a  Mild  Solution  of  Cocaine  in  Boric  Acid — Solutions 
must  be  Freshly  Prepared — Objections  to  the  Boric  Acid, 
owing  to  the  Formation  of  Mould  or  Fungi — Hypodermic 
Syringe  must  be  kept  Sci'upulously  Clean — Cocaine  in  the 
Treatment  of  Diseases  of  the  Eye — Ordinary  Cases — Gon- 
orrhceal  Ophthalmia — Cocaine  and  Atropia  in  Iritis — The 
Use  of  Solution  of  Cocaine  Hydrochlorate  in  Ear  Disease  — 

Deafness  from  Coryza  Treated  by  Cocaine 83-91 

CHAPTER  X. 

Local  Anaesthetics — Oil  of  Eucalyptus,  which  also  has  decided 
Antiperiodic  Powers,  and  Stimulating  Expectorant — Ether 
with  Dr.  B.  W.  Richardson's  Atomizer  as  a  Local  Anaes- 
thetic— Rhigolene  Employed  and  Described  by  Dr.  H.  J. 
Bigelow,  of  Boston  ;  also  by  Drs.  Edes,  Dana  and  Jacobi — ■ 
Rhigolene  to  Dissolve  Camijhor  and  Spermaceti  Dressing 
for  Burns ;  also  to  Dissolve  Iodine — Methyl  and  Chloride  of 
Methyl,  the  latter  Employed  in  Neuralgia  by  Dr.  Jacobi, 
of  New  York — Also  Condensed  Carbolic  Acid  Valuable  in 
Sciatica— Di'umine  found  to  be  not  of  much  Value — Hy- 
drastis Canadensis  (Golden  Seal) — Active  Principle  Hy- 
drastine- — Physiological  Action  Applicable  in  Catarrhal 
Stomach,  Eye,  Ear,  Nose  and  Throat ;  also  in  certain  Skin 
Affections  —Dose,  Formula  for  Injections  in  Gonorrhoea 
and  Leucorrhcea  — Homatropine,  Mydriatic,  Narcotic,  Sed- 
ative and  Ausesthetic— Chlorohydrate  of  Ei^hedrine — 
Dr.  Frommuler's  Opinion — Hydrobromate  of  Homatro- 
pine—Study  by  Drs.  Risley  and  Jackson,  Philadelphia 
— Brucine  Introduced  by  Dr.  Mays,  of  Philadelphia — 
Experiments  by  the  Author — Dr.  L.  Brunon's  Experi- 
ments with  Bruciiie — Lewenin  Allied  to  Cocaine,  but 
much  Inferior  to  it — Apomorphiae  Hydrochloras  -  Ery- 
throphleine,  or  Haya — "  Dr.  Lewein "  on  the  Proper 
Strength  of  its  Solution  for  Anaesthetic  use— "Karewski" 
1* 


10  TABLE    OF    CONTENTS. 

Pagk. 
never  obtained  Complete  Anaesthesia— The  Disagreeable 
After-Eflect— Caffeina — Cafteiue — Trials  of  Caffeine  as  a  Lo- 
cal Anesthetic  have  not  been  satisfactory — Theine,  Chemical 
Nature  like  Calleine,  both  valuable  Diuretics — Ilelleborine, 
from  the  Helifborus  niger,  two  Active  Principles  which  are 
Glucosides;  the  first  has  been  Employed  as  a  Local  Anaes- 
thetic— Canadol,  Volatile  Product  from  Naphtha,  Substitute 
for  Ether  as  a  Local  Anaesthetic  in  Richardson's  Spray  Ap- 
paratus— Menthol,  or  Oil  of  Peppermint  Camphor,  Rube- 
facient, and  Combined  with  Hypnotics  a  Local  Anfesthetic 
— Useful  in  Diseases  of  the  Throat  and  Nose— Formula — 
Iodoform  :  Preparation,  Solubility,  Dose  and  Mode  of  Ad- 
ministration— In  Inhalation,  Topical  Application,  its  Ac- 
tion on  Bacilli  and  Leucocytes — Disagreeable  Effects,  How 
Diminished — Iodoform  (Cotton  Wick)  as  a  Tampon  for 
Drainage — Deodorized  Iodoform  and  Ointment — Iodoform 
in  Variola— Colleville  Method,  Preventing  Scarring— In- 
creasing the  Antiseptic  Powers  of  Iodoform — An  Antidote 
for  Iodoform  Treatment  of  Diarrhcea  by  Iodoform  and 
Charcoal — On  the  Local  Use  of  Iodoform  in  Ear  Disease 
and  Dental  Operations — The  Late  Dr.  Cassell,  of  Glasgow; 
his  Conclusions  after  using  this  Agent — Nerve  Paste  in 
Dental  Operations — Iodoform  Gauze  Tampons — The  Anti- 
Bacterial  Action  of  Iodoform,  by  Dr.  I.  A.  Jeffries,  of  Bos- 
ton—Dr.  Robert  T.  Weir  and  Dr.  Weeks,  of  New  York, 
on  Iodoform  as  an  Antiseptic— lodol.  How  Pi'oduced — In 
the  Place  of  Iodoform — Author's  Exiierience — Dr.  Assaky, 
of  Bucharest,  Roumania,  Experiments  with  it — Dose — lodol 
is  an  Antipyretic  Toxic  Powder — Formulas  for  Powder — 
Solutions— Pastilles,  Bougies,  lodol.  Wool  and  Gauze  for 
Dressings  in  Chronic  Pharyngitis  and  Laryngeal  Phthisis 
— "Lublinski's  "  Method — In  the  Form  of  Spray  or  Brush 
in  Naso-Pharyngeal  Atrophic  Catarrh— A  Summary — 
Iodoform  and  lodol— The  Poisonous  Nature  of  Iodoform 
and  Greater  Safety  of  lodol — lodol  in  Diphtheria— Tests  of 
the  Statements  of  Drs.  Mazzoni  and  L.  L.  Stenibo,  of  Vilna 
— Trousseau's  Formulas — The  Doses  Employed  by  Drs. 
Pick  and  Assaky — Dr.  Harlan,  of  Chicago,  Combines  lodol 
and  Terebene  as  a  Topical  Application  in  Treatment  of 
Necrosed  Bone  and  Pyorrhcca  Alveolus— Combined  with 
Oleum  Gaultheriffi  as  an  Antiseptic  in  Destroying  the  Odors 
of  Diseased  Teeth  and  Relieving  Pain  -  Bromide  of  Ethyl 


TABLE    OF    CONTENTS.  11 

Pack. 

as  a  Local  Anseslhetic  by  the  Ordinary  Atomizer  of  David- 
son, of  Boston — Bromide  of  Potassium  as  a  Local  Anscs- 
thetic  for  Urinary  and  Sexual  Apparatus — Experiments  of 
J.  Kijanizyer,  St.  Petersburg — Ethyl  Iodide,  an  Anaesthetic 
and  Anti-Spasmodic — Chloral  and  Camphor  as  a  Local  An- 
aesthetic— Recommended  by  Dr.  Fordyce  Barker  to  Stop 
Secretion  of  Milk — Experiments  of  Dr.  Lapthorn  Smith, 
of  Montreal,  Canada — The  Local  Anaesthetic  Action  of  the 
Resin  from  the  Piper  methysticum  (Kava),  also  Benzol  De- 
rivatives, as  Naphthalin — Its  Action  on  the  Eye — Carbolic 
Acid — Forms  used  in  Medicine — Impure  and  Pure  Acid — 
Physical  and  Chemical  Properties — Applied  to  the  Skin — 
Dose— Poisoning  by  Carbolic  Acid  and  Treatment  of— Deaths 
from  Carbolic  Acid — Quinine,  Antipyrin  and  Antifebrin  as 
Antipyretics  and  Anaesthetics — Employment  of  Quinine  by 
the  late  Dr.  Fenner,  of  New  Orleans — Antipyriu-r-Composi- 
tion  and  Uses — Dose — Value  in  Various  Diesases — Caution 
in  its  Use — Its  Value  in  Migraine  and  Dysmenorrhcea — 
Antipyrin  as  an  Anaesthetic — Its  Local  Action — Experi- 
ments by  Berdach  and  Frankel — Value  in  Chronic  Catarrh  91-117 


PART    SECOND. 

CHAPTER  XT. 

Nitrogen  Monoxide — Nitrous  Oxide — Its  Mode  of  Preparation 
and  Chemical  Composition — Mode  of  Purification — Gasom- 
eter and  Mode  of  Receiving  and  Storing  Nitrous  Oxide  Gas 
— Gasometer  and  Inhaler  Combined— Iron  Retorts  for  Mak- 
ing Large  Quantities  of  Protoxide  of  Nitrogen — Thomas's 
Nitrous  Oxide  Inhaler — The  Second  Form  of  Inhaler,  vrith 
Hood  Modified  by  S.  S.  White  &  Co.,  of  Philadelphia— In- 
flatable Face-Piece  for  Inhaler — Liquid  Nitrous  Oxide  Gas — 
How  Made— Johnston  Gas  Valve — Nickel-plated  Gasometer 
for  Liquid  Nitrous  Oxide  of  500  gallons,  Care  and  Mode  of 
Employing  it,  Section  and  Form,  with  Illustration  of  Nickel- 
plated  Gasometer — Directions  for  Setting  up  and  Using  Gas- 
ometer— Wall-Bracket  for  Gas  Cylinder — Nitrous  Oxide 
Gas  for  Minor,  and,  in  a  few  instances.  Major  Operations 
(See  cases  reported  by  Dr.  C.  A.  Brackett,  of  Newport, 
and  Dr.  Goodwillie,  of  New  York) — Brief  Hints  as  to  the 


12  TABLE   OF   CONTENTS. 

Paoi. 
Proper  Method  of  Administering  Nitrous  Oxide  Gas  as  an 
Anesthetic — Sphygmographic  Tracings  from  Patients  under 
the  Influence  of  Nitrous  Oxide  Gas — Average  Time  for  Pa- 
tient to  come  Fully  under  Anaesthetic  Influence  of  the  Gas 
— Recovery  from  Influence — Clover's  Imjiroved  Apparatus 
for  Nitrous  Oxide  and  Ether — Mode  of  Arranging  Ether 
Inhalation  with  Thomas's  Gasometer  or  Clover's  Small 
Portable  Ether  Api^aratus— Attachments  for  Gas  Cylinders, 
Devised  by  Lewis,  of  Buffalo,  and  Dr.  A.  M.  Long — Ex- 
periments Reported  by  Dr.  Guilford  of  Mixtures  of  Ether 
and  Nitrous  Oxide  Gas — Codman  &  Shurtleff's  Inhaler 
of  Nitrous  Oxide  and  Ether — The  Physical  Properties  and 
Physiological  Action  of  Nitrogen  Monoxide — Dr.  C.  A. 
MacMunn  on  the  Spectroscope  in  Examination  of  the 
Blood — Experiments  on  the  Blood  Charged  with  Nitrous 
Oxide  by  the  late  Dr.  J.  H.  McQuillen,  F.  R.  Thomas  and 
the  Writer — The  Spectroscoj^e  and  its  Relations  to  Anes- 
thetics, by  Dr.  Waterman — Quotations  from  Herrman, 
Hoppe  Seyler,  Gorup  Besanez  and  W.  Preyer — Experi- 
ments with  Spectroscopic  Studies  of  the  Blood  charged  with 
Nitrous  Oxide  were  made  by  the  Writer,  the  late  Prof.  J. 
G.  Richardson,  assisted  by  Dr.  Wm.  M.  Hodges,  of  New 
York,  and  Author's  son,  Dr.  C.  S.  TurnbuU,  of  Philadelphia 
— Additional  Facts  in  Reference  to  the  Physiological  Ac- 
tion of  Nitrous  Oxide,  by  Dr.  D.  W.  Buxton,  of  London — 
Hyperoxygenation  Theory  of  Colton — Zimmerman  and  Dr. 
Frankland's  Experiments ;  also  those  of  Jolyet  and  Blanche 
and  Dr.  Buxton — Bonwill's  Suggestion  of  Rapid  Breath- 
ing to  Produce  Ansesthesia — Experiments  with  Nitrous 
Oxide  by  Dr.  Buxton,  on  the  Spinal  Cord— Professor  Hors- 
ley  on  Patellar  Phenomena — Dr.  Buxton's  Conclusions  in 
Regard  to  Nitrous  Oxide — The  Author's  Opinions  and  his 
Conclusions  in  Reference  to  Nitrous  Oxide  in  Four  Deduc- 
tions or  Statements 118-171 

CHAPTER  XII. 
On  the  Safety  of  Nitrous  Oxide— The  After-Effects  of  Nitrous 
Oxide  Gas,  by  Dr.  Guilford  and  Dr.  J.  D.  Thomas — Acci- 
dents in  Extracting  Teeth  under  Nitrous  Oxide,  Hints  from 
Dr.  Buxton  Administering  Nitrous  Oxide  to  Children — 
Death  from  the  Inhalation  of  Nitrous  Oxide — A  Case  in 
which  a  Cork-Prop  was  found  in  the  Larynx  of  the  Patient 


TABLE    OF    CONTENTS.  13 

Paoe. 
— Distressing  Symptoms  in  Two  other  Cases  in  which  a 

Piece  of  a  Tooth  passed  into  the  Trachea,  and  even  the 
Bronchia,  causing  all  the  Symptoms  of  Phthisis ;  these  two 
patients  recovered — Second  Case :  Dr.  Newbrough,  New 
York — Third  Case  :  Mr.  George  Morley  Harrison,  at  Man- 
chester, 'England— Tost-mortem  Observations  by  Dr.  Clo- 
ver —Fourth  Case :  patient,  Mr.  Samuel  P.  Sears ;  operator, 
Mr.  Jose  E.  Brunet,  D.D.S— Fifth  Case :  Miss  Wyndham, 
of  Exeter,  England;  operator.  Dr.  F.  F.  Mason — Sixth 
Case :  patient,  M.  Lejeune ;  operator,  Duchesne,  Paris — 
Seventh  Case :  Dr.  L.  P.  Twadell — A  Death  after  the  Use 
of  N  itrous  Oxide  :  patient,  Samuel  J.  Cresswell ;  operator, 
Dr.  John  D.  Thomas  [Note  :  No  post-mortem  was  made, 
and  the  Coroner  and  physicians  gave  a  certificate  that  Mr. 
Cresswell  died  from  apoplexy,  and  had  completely  recovered 
from  the  effects  of  the  gas,  and  that,  according  to  Dr. 
Thomas,  he  had  previously  inhaled  the  gas  with  impunity. 
He  had  been  attended  by  one  of  the  physicians  pi'eviously 
for  dyspeptic  symptoms] — Therapeutic  Application  of  Ni- 
trous Oxide— Nervous  Aphonia — Local  Paralysis — Asthma 
— Epilepsy — Therapeutics  of  Nitrous  Oxide,  by  Dr.  A.  Mc- 
Lane  Hamilton,  of  New  York — Dr.  Colton  on  the  Safety  of 
Nitrous  Oxide  Gas  in  Disease  of  the  Lungs,  Heart,  Chorea, 
Hysteria,  Epilepsy,  Asthma  and  Paralysis — Nitrous  Oxide 
and  Oxygen  as  an  Anaesthetic  in  Labor,  by  the  late  Paul 
Bert  and  Dr.  Si  Klikovich,  of  St.  Petersburg,  and  Profes- 
sor Zweifel,  of  Erlangen — Clover's  Inhaler  for  Nitrous  Ox- 
ide Gas  and  Ether,  with  his  Valuable  Conclusions — Dr.  F. 
N.  Otis'  Use  of  Clover's  Apparatus— How  shall  Nitrous 
Oxide  and  Ether  be  Administered  ?  by  Dr.  Frederick  W. 
Silk  and  Dr.  Hewitt,  of  London — Death  under  the  Admin- 
istration of  Nitrous  Oxide  and  Ether — Mixtures  of  Nitrous 
Oxide,  Ethers,  Chloroform  and  Alcohol  for  Inhalation — 
Oxygen  Gas  as  an  Anesthetic — Dr.  Gray,  of  Richmond, 
Va. :  his  Experiments — Bert,  Pfliiger,  Carpenter  and  A.  H. 
Smith's  Experiments — Pure  Oxygen  and  Apparatus  for  its 
Therapeutic  Administration — Oxygen  Gas  Enema  Appara- 
tus— Caution  in  its  Administration — Formula  and  Mode  of 
Preparing  Oxygen  Gas — Opinions  of  the  Dangers  and  Value 
of  Oxygen  Gas,  by  Dr.  J.  Solis-Cohen,  Philadelphia — De- 
marquay,  of  France — Report  of  a  Case,  by  Dr.  Simeon  Ab- 
rahams, of  Asphyxiation  from  Chloroform,  and  Recovery 


14  TABLE   OF   CONTENTS. 

Paob. 
by  the  Use  of  Oxygen  Gas — Report  of  a  Case  of  Opium 
Poisoning  in  which  the  Oxygen  Gas  was  successfully  used 
by  Dr.  Const.  Paul — Two  Cases  of  Recovery  reported  by  Dr. 
Sieveking — Croup  Treated  by  Dr.  Andrew  H.  Smith  with 
Oxygen  Gas — Biegel  on  the  Value  of  Oxygen  Gas  in  Chil- 
dren Predisposed  to  Phthisis — Dr.  Lasukewitch  on  the 
Physiological  Action  of  Oxygen — Dr.  Loy.ssel's  Experi- 
ments with  Pure  Oxygen — Favr  on  the  Use  of  Oxygen  in 
Puerperal  Eclampsia — Miguel  on  Oxygenated  Water  as  an 
Antiseptic — Dugardin  Beaumetz  Employs  Oxygen  Gas  in 
Anorexia • 171-213 


PART    THIRD. 

Alcohol,  U.  S. 

CHAPTER  XIII. 
The  Different  Kinds  of  Alcohol — The  Alcohol  recognized  by  the 
U.  S.  Pharmacopoeia — Absolute  and  Dilute  Alcohols — The 
Alcohol  in  Whiskey,  Wine  and  Brandy — Amylic  Alcohol 
— The  Toxic  Action  of  Alcohol — The  Action  on  the  Heart 
in  Moderate  Doses — Heat-Producing  and  Waste-Prevent- 
ing Action  of  Alcohol — Physiological  Action  of  Alcohol — 
Alcohol  as  an  Antesthetic — Views  of  Richardson,  Link  and 
Others — Toxicology — Treatment  of  Acute  and  Alcoholic 
Poisoning 213-219 

CHAPTER  XIV. 
ETHER. 
Manufacture — Chemical  Reaction  and  Composition — Tests  of 
Purity,  Inflammability — Ether  Fortior  —  Dr.  Squibb'a 
Ether — Tin  or  Glass  in  Preserving  Ether — Inflammability 
of  Ether — Influence  of  Ether  on  the  Brain  and  Pulse — The 
Ordinary  Method  in  Use  for  the  Administration  of  Ether : 
Towel,  Cone — Precautions  to  be  employed  before  and  after 
using  Ether,  and  Treatment  of  Dangerous  Symptoms  .    ,   .220-237 

CHAPTER  XV. 
Sudden  Deaths  under  Ether — Internal  Administration  of  Ether 
— Ether  in  Mitigation  of  the  Agonies  of  Death — Ether  In- 
toxication— Vivisection  with  Ether 237-264 


TABLE    OF    CONTENTS.  15 

Page. 
CHAPTER  XVI. 

Ethers  which  have  Ansesthetic  Properties— Acetic  Ether — Ex- 
periments by  Dr.  H.  C.  Wood  oa  Animals,  etc. — Formic 
Ether — Byassoii's  Conclusions  in  regard  to  it — Hydriodic 
Ether — Properties  and  Objections  to  its  Use — Methylic 
Ether — Dr.  Richardson's  Experiments  with  it — Bichloride 
of  Methylene — Observations  upon  it  by  Dr.  Jones,  of  Cork, 
Dr.  Taylor  and  Spencer  Wells,  of  London — Ethyl  Iodide — 
Ethylene  Bromide — Iodoform — Carbon  Dichloride— Brom- 
oform — Tetrachloride  of  Carbon — Butyl  Chloride — Chlor- 
ide and  Bichloride  of  Ethylene— Ethyl  Nitrate — Iodide  of 
Methyl — Amylene — Chloral  Hydrate — Acetic  Aldehyde   .  265  -285 

CHAPTER  XVII. 

Etherization  by  the  Rectum 286-293 

CHAPTER  XVIII. 
Hydrobromic  Ether  or  the  Bromide  of  Ethyl  (C2H.Br) — Chem- 
ical Nature,  Properties,  Decomposition,  etc. — As  an  Anses- 
thetic in  Labor,  in  Dental  Operations — Table  of  the  Purity 
of  Various  Specimens  of  Bromide  of  Ethyl 293-332 

CHAPTER  XIX. 

ETHEE  INHALEKS. 
The  Cone — Inhalers  of  Hawksley,  Ormsby,  Hearn,  Cheatham, 
Lente,  Allis,  Morgan,  Richardson,  Angrove — An  Improved 
Ether  Inhaler  by  Parkinson — Rapid  Anassthesia  by  Ether, 
Miiller,  and  Corning  Device — Clover's  Inhalers   .....  333-364 


PART    FOURTH. 

CHAPTER  XX. 

CHLOROFORM. 
Chloroform — Dichlorinated  Chloride  of  Methyl — Terchloride 
of  Formyl  (CHCls) — Clover's  Chloroform  Apparatus — Tox- 
icological  Effects  of  Chloroform— Prevention  of  Fatal  Re- 
sults— Sims  on  Resuscitation — Dr.  Watson's  Experiments 
— The  Experiments  of  Drs.  Hare  and  Martin;  also  Appara- 
tus for  the  Treatment  of  Cases  of  Arrested  Respiration,  etc. 


16  TABLE   OF   CONTENTS. 

Paqk. 
— Tlie  Selection  of  an  Auresthetic — Deaths  from  Chloroform 
— Chloroform  given  Improperly — Ratio  of  Deaths  from  An- 
aesthetics— Table  of  Deaths  from  the  Various  Anaesthetics 
— Junker's  Inhaler 365-443 

CHAPTER  XXL 

Legal  Responsibility  of  Physicians  in  the  Administration  of  An- 
aesthetics— Medico-Legal  Relations  of  Anesthetics — Case  of 
a  Surgeon  Dentist — The  Important  Question  whether  Chlo- 
roform can  be  Administered  for  Criminal  Purposes — Cases 
in  France,  England  and  the  United  States — Dr.  N.  L.  Fol- 
som,  R.  M.  Denig — Chloroform  as  a  Poison — The  Chloro- 
form Habit — Use  of  Morphine  with  Chloroform — Mixed 
Anffisthetics — Mixed  Anesthetics  in  Ophthalmic  Surgery 
— The  Inhalation  of  Chloroform  and  Ether  the  Cause  of 
Aural  Disease — Brief  Extracts  and  Exjieriments  with  a 
Mixture  of  Ether  and  Bromide  of  Ethyl  and  Chloroform — 
Anesthesia  by  Chloroform  and  Oxygen — Employment  of 
Chloroform  in  Labor— Practical  Observations  on  the  Inju- 
rious Eifects  of  Chloroform  Inhalation  during  Labor — 
Effects  of  Prolonged  Chloroform  Anaesthesia  on  Dogs — An 
Abstract  of  the  Reports  of  Recent  Deaths  from  a  Mixture  of 
Ether  and  Chloroform — Accidents  Accompanying  the  Use  of 
the  A.-C.-E.  Mixture — Chloroform  and  Morphia,  Ether  and 
Morphia — Mixed  Narcosis — Presence  of  Albumen  in  the 
Urine  after  the  Administration  of  Chloroform — The  Influ- 
ence of  Nitrite  of  Amyl  in  Counteracting  the  Depressing 
Effects  of  Ether,  Chloroform  and  Cocaine  during  Anesthe- 
sia— Hyijnotism  as  an  Anesthetic— Therapeutic  Hypnot- 
ism—Hypnotics  or  Soporifics — A  List  of  the  Chief  Hypno- 
tics— A  List  of  General  Anesthetics — A  New  Method  of 
Producing  Anesthesia — Insanity  following  the  Use  of 
Anesthetics  in  Operations— Ether  or  Chloroform,  Which? 
— Conclusion :  On  the  Choice  of  Anesthetics  and  the  Im- 
portance of  Great  Caution  in  Producing  Anesthesia  .    .    .  443-521 


ARTIFICIAL  ANiESTHESIA. 


PAET    FIRST, 


CHAPTEE    I. 

History  of  Ancient  and  Modern  Anaesthetics. 

The  Ancient  Greeks,  it  is  stated,  possessed  a  plant  called 
mandrake.  It  belonged  to  the  same  family  of  plants  as  bella- 
donna, or  deadly  night-shade.  From  the  root  of  this  plant  was 
extracted,  by  means  of  wine,  a  narcotic  which  was  employed 
by  them  as  an  anaesthetic.  Lucius  Apuleius,  who  lived  about 
160  A.D.,  and  of  whose  works  eleven  editions  were  republished 
in  the  fourteenth  and  fifteenth  centuries,  says,  "that  if  a  man 
has  to  have  a  limb  mutilated,  sawn,  or  burnt,  he  may  take  half 
an  ounce  of  mandragora  wine,  and  whilst  he  sleeps  the  member 
may  be  cut  off  without  pain  or  sense."  To  prove  that  this  was 
true.  Dr.  B.  W.  Richardson,  of  London,  after  a  lapse  of  five 
centuries,  obtained  a  fine  specimen  of  mandragora  root,  and 
after  making  wine  from  it  and  testing  it,  found  it  was  a  narcotic 
having  precisely  the  properties  that  were  anciently  ascribed  to 
it.  He  discovered  that  in  animals  it  would  produce  even  the 
sleep  of  Juliet,  not  for  thirty  or  forty  hours,  a  term  that  must 
be  accepted  as  a  poetical  license,  but  for  the  four  hours 
named  by  Dioscorides;  and  that  on  awakening,  there  was  an 
excitement  which  tallied  with  the  same  phenomenon  that  was 
observed  by  the  older  physicians.  Another  fact  was  noticed 
by  the  ancients  that  many  volatile  substances  acted  more 
promptly  by  inhalation  than  by  the  stomach,  and  this  form  of 
medication  was  employed  in  Greece,  Rome  and  Arabia.     By 

17 


18  ARTIFICIAL,   ANESTHESIA. 

the  works  published  in  these  countries  the  knowledge  of  the^e 
facts  was  extended  to  other  parts  of  the  world.  "  He  has  eaten 
mandrake,"  was  said  of  a  very  indolent  and  sleepy  man,  from 
the  narcotic  and  stupefying  properties  of  the  plant,  well  known 
to  the  ancients, 

Cleopatra. — "Give  me  to  drink  mandragora 

That  I  might  sleep  out  this  great  gap  of  time 
My  Anthony  is  away." 

— Shakespeare,  "Anthony  and  Cleopatra,"  act  i.  scene  5. 

In  China,  in  ancient  times,  the  word  ma-yo  meant  not  only 
Indian  hemp,  but  anaesthetic  medicine;  other  substances  besides 
hemp  entered  into  these  benumbing  recipes,  such  as  the  datura, 
a  solanaceous  or  soothing  plant,  probably  identical  with  the 
atropia  mandragora;  also  aconite,  hyoscyamus,  etc.  Some  of 
these  drugs  form  constituents  of  the  formula  said  to  be  em- 
ployed by  kidnappers  of  children,  and  by  robbers;  consequently 
their  sale  or  employment  is,  at  the  present,  prohibited  in  China. 
Dr.  Dudgeon,  of  Pekin,  writing  in  1877,  gave  a  flat  contradic- 
tion to  the  extravagant  stories  current  in  Europe  respecting  the 
skillful  use  made  by  the  early  Chinese  of  benumbing  drugs,  and 
probably  a  more  exact  acquaintance  with  the  facts  would  show 
that  the  practice  of  Greece  and  Rome  was  not  less  elementary. 
Only  in  modern  times,  and  in  the  light  of  scientific  teaching, 
was  it  possible  for  anaesthetics  to  take  their  proper  place  as  the 
helpmate  of  the  surgeon  in  his  art,  and  as  the  grand  alleviator 
of  human  suffering. 

Theodoric,  about  the  year  1298,  gives  elaborate  directions 
how  to  prepare  a  "spongia  somnifera"  by  boiling  it  dry  in 
numerous  strong  narcotics,  and  afterwards  moistening  it  for  in- 
halation before  operations. 

Opium  was  also  employed  in  later  year.^  (prior  to  surgical 
operations),  and  was  found  the  best  narcotic  for  the  relief  of 
pain  and  for  producing  insensibility,  but  was  not  free  from 
danger. 

History  of  Modern  Anajstliesia  and  Anaesthetics. 

On  September  3,  1828,  M.  Girardin  read  to  the  Academy  of 


MODERN    ANESTHESIA    AND    ANESTHETICS.         19 

Medicine,  of  Paris,  a  letter  addressed  to  His  Majesty,  Charles 
X.,  describing  surgical  anaesthesia  by  means  of  "  inhaled  gases." 

A  strong  impulse  was  given  to  the  study  and  application  of 
the  "different  kinds  of  airs  and  gases"  by  the  discovery  of 
oxygen  by  Priestly  and  Scheele  in  the  middle  of  the  last  cen- 
tury, and  numerous  experiments  were  made  by  physicians  with 
it. 

Pneumatic  chemistry  called  into  existence  a  new  branch  of 
therapeutics — pneumatic  medicine,  as  it  was  named  by  its 
founders,  who  hoped  to  cure  diseases,  especially  consump- 
tion, by  the  inhalation  of  various  gases  and  vapors.  This  has 
been  again  revived  in  our  day.  A  "Medical  Pneumatic  In- 
stitution "  was  set  up  at  Clifton,  in  1798,  by  Dr.  Beddoes,  with 
huge  reservoirs  of  gases  for  the  use  of  patients.  The  celebrated 
Humphrey  Davy,  then  just  out  of  his  apprenticeship,  was  ap- 
pointed superintendent.  Though  not  successful  in  the  imme- 
diate object  for  which  it  was  founded,  it  was  so  in  another 
sense;  for  here,  Davy  made  his  researches  concerning  nitrous 
oxide  gas.  In  1800  he  discovered  that  when  inhaled,  it  pro- 
duced a  peculiar  intoxicating  effect,  with  irresistible  propensity 
to  muscular  exertion,  and  often  to  laughter,  whence  its  popular 
name  of  "laughing  gas."  He  also  discovered  its  anaesthetic 
properties,  and  successfully  inhaled  it  himself  to  relieve  the  pain 
of  cutting  a  wisdom  tooth.  He  made  numerous  experiments 
with  it  on  animals.  In  his  account  of  these  experimients  there 
occurs  this  memorable  and  oft-quoted  sentence:  "As  nitrous 
oxide  in  its  extensive  operation,  appears  capable  of  destroying 
physical  pain,  it  may  probably  be  used  to  advantage  during 
surgical  operations  in  which  no  great  effusion  of  blood  takes 
place."  Those  desirous  of  pursuing  the  subject  further  should 
read  his  work  entitled  "Researches,  Chemical  and  Philosophi- 
cal, chiefly  concerning  Nitrous  Oxide."  Strange  to  relate, 
notwithstanding  their  completeness,  nothing  came  of  these  re- 
markable observations.  Their  real  import  was  not  understood 
until  nearly  half  a  century  later. 

The  modern  practice  of  anaesthesia,  though  it  may  have  bene- 
fited indirectly  by  these  experiments,  was  not  the  immediate 
outcome  of  auy  of  them;  it  originated  to  a  large  extent  inde- 


20  ARTIFICIAL   ANESTHESIA. 

pendently.  The  honor  of  making  ihis  discovery  rests  chiefly 
with  four  Americans, — Horace  Wells,  William  Morton,  Charles 
Jackson  and  Crawford  W.  Long. 

One  winter's  night  in  December,  1844,  a  number  of  the  in- 
habitants of  Hartford,  Connecticut,  assembled  to  hear  a  lecture 
on  nitrous  oxide  and  other  gases,  from  Dr.  Colton,  a  well-known 
popular  lecturer,  who  tried  the  effect  of  the  first-named  gas  on 
several  of  the  audience.  Among  those  present  were  Horace 
Wells  and  his  friend  John  M.  Riggs,  dentists  of  that  city.  They 
noticed  that  a  person  under  its  influence  sustained  a  severe  in- 
jury of  his  leg,  without  apparently  feeling  any  pain.  Wells 
was  so  impressed  with  this  fact,  that  next  day  he  got  the  lectu- 
rer to  give  him  the  gas,  and  whilst  under  its  influence  he  had 
a  molar  tooth  extracted,  without  feeling  the  least  pain.  As  he 
recovered  from  the  effects  of  the  gas  his  first  words  were:  "A 
new  era  in  tooth-pulling." 

The  modern  practice  of  anaesthesia  dates  from  this  operation. 
Wells  appears  to  have  been  unaware  of  Sir  Humphrey  Davy's 
experiments.  He  found  the  peculiar  intoxicating  effects  de- 
scribed by  Davy  due  to  mixture  of  the  gas  with  atmospheric 
air;  for  when  precautions  had  been  taken  to  exclude  the  latter, 
only  anaesthetic  effects  ensued  from  its  inhalation. 

He  gave  the  gas  to  more  than  a  dozen  of  his  patients,  and 
with  complete  success.  Elated  with  this  good  fortune,  he  quickly 
obtained  permission  to  make  public  trial  of  it  at  the  Massa- 
chusetts General  Hospital.  Unfortunately,  the  bag  was  re- 
moved too  soon,  and  in  the  extraction  of  the  tooth  the  patient 
uttered  a  piercing  cry.  The  skeptical  audience  rudely  hooted 
and  hissed,  and  he  was  laughed  at  as  an  ignorant  pretender. 
Now,  Wells  was  a  modest  and  retiring  man;  he  felt  the  insult 
deeply.  Home  he  went,  mortified  and  disgusted,  yet  both 
Wells  and  Riggs  continued  in  their  practice  to  administer  the 
gas,  but  never  afterwards  resumed  their  experiments  in  public. 
After  a  few  years  Wells  fell  ill  from  vexation,  and  retired  from 
his  profession.  Subsequently,  he  visited  Europe  as  a  picture 
dealer,  then  returned  to  the  United  States,  became  more  and 
more  unsettled  in  his  mind,  and  finally  died  by  his  own  hand 
in  January,  1848.     For  a  long  time  Wells'  just  claims  as  the 


DISCOVERY   OF   MODERN   ANAESTHESIA.  21 

discoverer  of  modern  ansesthesia  were  ignored  ;  indeed,  we  are 
only  now  beginning  to  do  justice  to  his  memory.  He,  at  least, 
never  attempted  to  make  a  secret  of  his  great  discovery,  nor  to 
use  it  for  his  seliish  ends.  "  On  making  the  discovery,"  says 
Wells,  "  I  was  so  much  elated  respecting  it,  that  I  expended  my 
money  freely,  and  devoted  my  whole  time  for  several  weeks,  in 
order  to  present  it  to  those  who  were  best  qualified  to  investi- 
gate and  decide  upon  its  merits,  not  asking  or  expecting  any- 
thing for  my  services.  I  was  desirous  that  it  should  be  as  free 
as  the  air  we  breathe.  Judge,  therefore,  of  my  surprise,  after 
the  lapse  of  many  months,  when  I  was  informed  that  two  indi- 
viduals (Drs.  Jackson  and  Morton)  had  claimed  the  discovery, 
and  made  application  for  a  patent  in  their  own  names." 

We  are  happy  to  state  that  a  chaste  and  handsome  monu- 
ment, with  a  statue  of  Wells,  has  been  erected  at  Hartford, 
Connecticut,  with  the  following  inscription  : 

"  Horace  Wells,  who  discovered  Anassthesia, 
December  10th,  1844." 

Much  credit  is  due  to  Dr.  McManus  and  friends  of  Wells  for 
their  praiseworthy  efforts  in  this  matter. 

The  use  of  nitrous  oxide  as  an  anaesthetic,  for  the  time  being, 
died  with  Wells;  and  the  discovery  was  again  in  danger  of 
being  lost.  Dr.  Colton's  praiseworthy  efforts  to  re-introduce  it 
were  vain  until  1863,  when  he  succeeded  in  getting  a  few 
practitioners  to  try  it.  Its  use  spread  rapidly,  so  that  in  1867 
— the  year  of  the  International  Exhibition  in  London — he  was 
able  to  visit  Paris  with  a  record  of  20,000  administrations  with- 
out a  single  accident.  He  met  with  very  little  encouragement 
from  the  Paris  faculty ;  however,  in  the  spring  of  the  follow- 
ing year,  his  apparatus  was  brought  to  London  by  Dr.  Evans, 
the  American  dentist  resident  in  Paris,  who  administered  the 
gas  before  the  staff  of  the  Dental  Hospital,  and  thus  introduced 
the  practice  into  that  country.*  In  the  United  States  it  was 
well  received ;  and  in  1870  Dr.  Colton  published,  in  a  medical 

*  The  Jottrnal  of  the  British  Dental  Association. 


22  ARTIFICIAL   AN.^ESTHESIA. 

journal  and  afterwards  in  pamphlet  form,  the  result  of  the 
physiological  action  of  the  gas  in  practical  application  of  the 
original  discoveries  of  Davy,  Wells  and  others,  with  a  very 
large  record  of  successful  extraction  of  teeth. 

Unfortunately,  owing  to  its  comparative  feebleness  of  action 
(the  result  of  its  large  gaseous  bulk),  it  can  only  be  maintained 
for  a  very  limited  period.  Hence,  its  employment  has  hitherto 
necessarily  been  restricted  to  short  surgical  operations.  The 
late  M.  Paul  Bert,  has  partially  succeeded  in  overcoming  the 
above  objection  by  giving,  instead  of  the  pure  gas,  a  mixture 
of  it  with  oxygen  gas,  in  the  proportion  of  85  volumes  of  the 
former  to  15  volumes  of  the  latter,  under  increased  atmospheric 
pressure  in  a  special  chamber  constructed  for  this  purpose. 
The  necessity  for  the  latter  part  of  this  provision  arises  from 
the  fact  that  when  the  mixture  of  the  gases  is  inhaled  alone, 
complete  ansesthesia  cannot  be  produced,  owing  to  the  full 
complement  of  nitrous  oxide  (45  volumes  to  100  volumes  of 
oxygen)  not  being  taken  into  the  lungs  during  respiration. 
Under  the  above-mentioned  increased  pressure,  sufficient 
nitrous  oxide  is  inhaled  to  produce  an?esthesia,  and  sufficient 
oxygen  to  prevent  the  supervention  of  asphyxia.  Thus,  pro- 
longed ansesthesia  can  be  maintained.  After  many  experi- 
ments on  animals,  this  method  has  been  tried  at  the  Paris  Hos- 
pital, by  Peau  and  others,  and  with  partial  success.  It  is  not 
known  whether  it  is  employed  in  this  country.  The  requisite 
apparatus  in  its  present  form  is  too  cumbrous  and  expensive 
for  general  use. 


CHAPTER  II. 

The  Discovery  of  Special  Anaesthetics,  and  the  Theory  of  their  Ac- 
tion— Local  AnDesthebia  and  Ansesthetics. 

Ether. 

"Pereira,"  in  his  famous  work,  then  as  now  a  familiar  text- 
book, states,  "  the  vapor  of  ether  is  inhaled  ...  to  relieve 
the  effects  caused  by  the  accidental  inhalation  of  chlorine  gas." 


DISCOVEEY   OF   ETHER   AS   AN   ANESTHETIC.      23 

Again,  lie  writes,  "If  the  air  be  too  strongly  impregnated  with 
ether,  stupefaction  ensues."  The  crowning  result,  however, 
was  obtained  in  1846,  by  Dr.  Morton,  in  the  Massachusetts 
General  Hospital,  when  it  was  demonstrated  successfully  that 
the  inhalation  of  ether  was  so  capable  of  deadening  the  sensi- 
bility of  the  nervous  system,  that  an  operation,  no  matter  how 
painful,  could  be  performed  without  suffering  to  the  patient. 
In  the  use  of  ether  as  an  anaesthetic,  the  first  capital  operation 
— that  is,  one  involving  one  of  the  larger  joints — was  per- 
formed on  October  17,  1846,  by  Dr.  Warren,  of  Boston. 

Dr.  Jackson,  of  Boston,  claims  to  have  suggested  to  Dr. 
Morton  the  use  of  ether  as  an  anaesthetic,  in  place  of  nitrous 
oxide.  With  regard  to  this,  it  may  be  stated,  that  at  a  meet- 
ing of  the  Boston  Academy  of  Arts  and  Sciences,  where  the 
matter  was  being  discussed,  the  late  Professor  Louis  Agassiz 
said  to  Dr.  Jackson,  "  Did  you  make  even  one  little  experiment 
with  ether?"  and,  after  receiving  a  negative  reply,  added,  dryly, 
"It  would  have  been  better  if  you  had."  On  another  occasion 
Professor  Agassiz  said,  "  If  Dr.  Morton  bad  killed  his  first 
patient,  would  you  (Jackson)  have  accepted  the  blame,  just  as 
now  you  ask  for  the  honor?"  Dr.  Jackson  was  silent.  The 
names  of  Jackson  and  Morton  were,  however,  associated  in  an 
attempt  to  obtain  a  patent  for  the  process,  which  was  frowned 
upon  by  every  right-minded  physician  and  dentist. 

It  seems  that,  among  other  after-claimants,  one,  an  estimable 
physician  of  Georgia,  Dr.  Crawford  W.  Long,  wakened  to  the 
fact,  only  so  late  as  1849  (three  years  after  anaesthetic  inhalation 
by  ether — 1846 — had  been  in  universal  practice),  that  it  would 
be  well  to  record  in  some  medical  journal  the  statement  that 
he  had  "  used  ether  by  inhalation  in  surgical  operations  on 
several  occasions  "  (as  many  as  five  in  the  course  of  as  many 
years),  prior  to  1846.  He  accordingly,  in  December,  1849, 
published  "  an  account  of  the  first  use  of  ether  by  inhalation 
as  an  anaesthetic  in  surgical  operations."  This  communication, 
tardy  as  it  was,  Dr.  Long  very  properly  made,  in  simple  justice 
to  himself.  No  special  attention  was  paid  to  it,  for  reasons 
which  will  soon  become  apparent.  He  seems,  indeed,  merely 
to  have  desired  to  place  himself  on  record,  in  connection  with 


24  ARTIFICIAL   ANESTHESIA. 

this  subject  in  1849.  In  1877,  this  forgotten  record  is  dragged 
from  its  obscurity,  and  amplified  and  adorned  into  a  patent  of 
discovery.  The  interests  of  truth  will  be  best  served  by  re- 
ferring to  Dr.  Long's  original  text.  One  quotation  will 
establish  these  points.  We  shall  be  brought  straightway  to 
the  very  pith  of  the  case  by  the  following  summary,  as  given 
by  himself,  of  his  communication  of  1849,  already  referred 
to  :  "  The  result  of  my  second  experiment  in  etherization  was 
such,  as  led  me  to  believe  that  the  anaesthetic  state  was  of  such 
short  duration,  that  ether  would  only  be  applicable  in  cases  in 
which  its  effects  could  be  kept  up  by  constant  inhalation, 
during  the  time  of  the  performance  of  the  operation.  Under 
this  impression,  up  to  January,  1847,  I  had  not  used  ether  in 
but  one  case,  in  extracting  teeth,  and  thus  deprived  myself  of 
experimenting  in  the  only  class  of  cases  which  are  of  frequent 
occurrence  in  a  country  practice."  Now,  in  the  first  place,  the 
remarkable  admissions  contained  in  this  sentence  would  be 
valueless,  if  any  subsequent  experiments  had  taught  Dr.  Long 
more  than  he  here  enunciates ;  but  he  never,  of  himself, 
learned  more  than  this — for  he  distinctly  states  that  he  "  was 
under  the  impression"  embodied  in  this  quotation  until  Janu- 
ary, 1847,  three  months  after  the  announcement  of  universal 
and  practical  anaesthesia  in  1846. 

It  is  somewhat  remarkable  that  the  fate  of  almost  all  these 
claimants  to  the  discovery  of  anaesthesia  was  so  tragical.  We 
have  already  referred  to  the  sad  end  of  Dr.  Wells.  Dr.  Charles 
T  Jackson  died  at  Somerville,  Mass.,  August  30th,  after  a 
seven  years'  illness,  a  disappointed  man,  although  receiving 
an  honorarium  and  medal  from  the  Government  of  France. 
Morton,  having  been  reduced  to  poverty  during  the  long  twelve 
years  in  which  he  endeavored  to  wring  from  Congress  and  the 
courts  recognition  of  his  rights,  died  suddenly  in  New  York 
City,  in  1868,  of  cerebral  congestion,  brought  on,  it  is  said,  by 
reading  a  work  attacking  his  claims.  How  much  more  fortu- 
nate was  Professor  Simpson,  of  Edinburgh,  whose  introduction 
of  chloroform  won  for  him  a  baronetcy,  the  highest  honors  of 
his  profession,  a  statue  in  Edinburgh  and  a  memorial  bust  in 
Westminster  Abbey ! 


CHLOROFORM   AS   AN   ANESTHETIC.  25 

Long  was  the  happiest.  He  died,  comparatively  little 
known,  in  1878,  a  poor  man,  though  now  his  statue,  with  that 
of  Oglethorpe,  will  represent  Georgia  in  the  National  Gallpry 
at  the  Capitol.  Owing  to  the  bitter  controversy  that  resulted 
from  the  claims  of  Wells,  Morton  and  Jackson,  to  the  discovery 
of  ether  anaesthesia,  a  monument  was  erected  in  Boston,  with 
only  the  following  inscription : 

"  To  commemorate  the  discovery  that  the  inhalation  of  ether 
causes  insensibility  to  pain.  First  proved  to  the  world  at  the 
Massachusetts  General  Hospital,  in  Boston,  October,  a.d. 
MDCCCXLVI." 

Chloroform. 

During  the  close  of  the  year  1847,  Professor  Simpson,  of 
Edinburgh,  brought  by  his  courage  and  perseverance  a  new 
and  valuable  an£e.sthetic  agent  into  use,  namely,  chloroform. 
This  was  the  suggestion  of  Dr.  Waldie,  a  chemist  of  Liverpool. 
He  had  found,  by  experience,  that  a  much  smaller  quantity 
was  required  to  produce  profound  ansesthesia,  it  being  more 
prompt  in  its  action  and  more  agreeable  to  the  patient  both  in 
taste,  and  odor.  Chloroform  had,  however,  a  great  drawback 
in  general  use  as  an  ansesthetic,  in  that  it  would  cause  very 
sudden  death. 

The  True  Value  of  Anaesthetics. 

No  one  can  form,  even  at  the  present  day,  a  just  estimate  of 
the  true  value  of  the  various  anaesthetics,  or  express  in  words 
their  wonderful  and  extended  application  to  the  relief  of  human 
suffering.  To  the  general  surgeon  it  gives  the  opportunity  of 
operating  in  grave  cases  of  disease  and  injury,  without  which 
the  death  of  the  patient  would  be  inevitable.  It  also  affords, 
by  the  immediate  relief  from  pain,  the  power  to^  manipulate 
the  broken  or  injured  parts  with  facility,  and  thus  obtain  a 
correct  diagnosis  in  the  most  obscure  diseases  and  painful 
accidents. 

To  the  obstetrician  and  gynaecologist,  it  is  most  valuable  in 
assuaging  the  terrific  pain  of  labor,  and  makes  the  dreaded 
instruments  a  blessing  in  disguise.  In  the  diagnosis  and  treat- 
ment of  abdominal  diseases,  it  gives  precision  and  almost  mar- 
2 


26  AKTIFICIAI.  ANAESTHESIA. 

veloua  results,  and  in  the  removal  of  large  masses  or  ovarian 
tumors,  great  freedom  from  the  dreadful  eifects  of  shock  to  the 
nervous  system.  For  the  ophthalmic  surgeon  the  ana'sthetic 
reduces  the  sensibility  of  the  eye  so  that  it  can  be  touched  and 
cut  with  impunity,  and  severe  and  dangerous  operations  can 
be  performed  upon  this  delicate  and  sensitive  organ  without 
pain  and  with  much  less  risk. 

Again,  in  the  removal  of  foreign  bodies  from  the  eye  or  ear, 
particularly  in  children,  by  the  use  of  the  anjcsthetic,  all  spasm 
is  relieved,  and  the  act  is  accomplished  without  injury.  The 
profound  sleep  gives  a  most  favorable  opportunity  to  the 
aural  surgeon  to  perforate  the  membrana  tympani,  cut  the 
minute  tendon  of  the  tensor  tympani  muscle,  or  perforate  the 
mastoid  cells. 

Theories  of  the  Manner  in  which  Anaesthetics 
Produce  their  Eftects. 

At  the  present  day  only  four  theories  are  received  to  ex- 
plain the  effects  of  general  anaesthetics  on  the  system. 

1.  That  they  act  by  retarding  oxidation  and  inducing  a  par- 

tial asphyxia. 

2.  That  they  produce  actual  changes  in  the  blood,  thus  caus- 

ing secondary  inhibition  of  the  function  of  the  sensory 
nerve  cells. 

3.  That  they  merely  bring  about  cerebral  anaemia,  from  which 

condition  anresthesia  results. 

4.  That  they  have   a  direct  action  upon  the  nervous  tissue 

itself. 

There  is  no  true  similarity  between  the  phenomena  of  true 
amesthesia  and  those  of  asphyxia ;  the  conditions  are  not 
identical,  and  when  true  asphyxia  takes  place  it  is  a  complica- 
tion which  is  to  be  avoided  with  all  anaesthetics,  especially 
nitrous  oxide  and  ether. 

In  regard  to  the  second  theory,  it  is  admitted  that  certain 
anaesthetics,  like  chloroform,  produce  changes  in  the  blood, 
and  if  carried  too  far,  these  changes  will  become  permanent ; 
they,  however,  are  neither  necessary  nor  essential  to  the  pro- 
duction of  true  antesthesia.     Dr.  H.  C.  Wood,  in  his  recent 


LOCAL   ANAESTHESIA   AND    ANiESTIIETICS.  27 

edition  of  his  work  (on  Therapeutics,  1888),  holds  that  the 
only  theory  at  all  compatible  with  our  present  knowledge  is, 
that  anfesthesia  is  in  most  cases  due  to  a  direct  action,  of  the 
agent  inducing  it,  upon  the  cortex  cerebri. 

Liocal  Antestliesia  and  Ansestlietlcs. 

Ansesthetics  are  now  divided  into  local  and  general,  and  in 
that  order  we  shall  take  them  up.  The  local  are  those  which 
abolish  the  sensibility  of  the  peripheral  or  surface  nerves  of  a 
particular  area  for  a  time. 

The  general,  or  systemic  ansesthetics  are  those  which  tempo- 
rarily suspend  sensation  of  the  entire  economy,  or,  if  carried 
to  their  full  power,  destroy  sensation  and  life. 

To  diminish  or  abolish  the  sensibility  of  the  skin  and 
mucous  membranes  in  regions  where  surgical  operations  are 
to  be  performed,  and  to  avoid  the  dangers  of  general  anaesthesia, 
is  a  matter  of  the  greatest  importance.  One  of  the  earliest  and 
most  efficient  means  of  accomplishing  local  anaesthesia  is  cold 
— either  ice  or  snow,  with  or  without  a  mixture  of  the  chloride 
of  sodium,  potassium,  ammonium  or  calcium — or  through 
the  rapid  evaporation  of  chloroform,  ether,  bromide  of  ethyl, 
rhigolene,  carbon  bisulphide,  absolute  alcohol,  benzol  and 
many  other  like  substances,  the  action  of  which  are  expedited 
if  they  are  applied  in  a  fine  spray. 

Chloroform,  ether  and  the  other  allied  substances  before 
mentioned,  not  only  act  on  the  peripheral  nerves  of  the  skin, 
and  produce  local  anaesthesia,  but  anaesthesia  may  be  caused 
by  these  agents  by  direct  action  on  the  nerve  cells  themselves 
applied  to  the  brain  or  nerve.  Thus  Prevost  found  that  chlo- 
roform applied  directly  to  the  brain  of  a  frog,  narcotized  it 
when  the  aorta  was  tied.  When  the  aorta  was  released,  so 
that  the  current  of  blood  could  wash  the  chloroform  away,  the 
narcosis  disappeared. 

The  limitation  of  the  anaesthetus  to  a  part  of  the  body  is 
much  safer  to  the  patient's  life,  and  the  local  anaesthetic,  is  pre- 
ferred when  we  wish  to  produce  anaesthesia  in  the  genito-anal 
region,  as  operations  in  and  about  thes3  parts  require  more  ether 


28  ARTIFICIAL   ANESTHESIA. 

and  chloroform  than  other  caaea.  This  is  also  the  case  in  the 
extremities,  as  in  the  fingers  and  toes.  In  proof  of  which  see 
the  number  of  deaths  following  the  use  of  systemic  aniesthetica 
in  operations  on  the  abdomen,  womb,  rectum,  in  hernia,  and 
for  the  simple  removal  of  hemorrhoids. 

At  a  meeting  of  the  Societe  de  Biologic,  of  Paris,  on  April  14, 
1888,  M.  Oscar  Liebreich  read  a  communication  on  substances 
which  cause  local  anfesthesia.  Having  been  led  to  experiment 
on  a  large  number  of  substances,  either  natural  or  produced 
by  synthesis,  he  found  that  there  were  a  great  many  more 
capable  of  causing  local  ansesthesia  than  had  been  supposed. 
Some  of  these  substances  have  an  effect  on  animals,  but  not 
on  man,  for  many  of  them  act,  not  by  entering  the  general 
circulation,  but  by  their  direct  effect  upon  the  tissues  with 
which  they  come  into  contact.  "With  regard  to  the  cornea,  it 
must  be  remembered  that  there  are  two  kinds  of  anfesthesia. 
M.  Liebreich  operated  by  subcutaneous  injection  of  the  dorsal 
region  in  rabbits  and  guinea-pigs.  For  the  eye,  he  merely 
allowed  a  few  drops  of  the  substance  in  solution  to  fall  on  the 
cornea.  Among  the  substances  producing  local  anicsthesia 
the  principal  are  hydrochlorate  of  ammonia  and  the  bromide 
and  sulphate  of  ammonia ;  the  carbonate  and  nitrate  are  with- 
out effect.  Sulphate  of  copper  is  inactive,  but  the  iron  salts, 
particularly  the  sesquioxide,  have  an  anaesthetic  action  without 
producing  coagulation  at  the  point  of  introduction.  Acetate 
of  lead  is  anaesthetic;  zinc  salts  are  not.  Among  organic  sub- 
stances, hydroquinine,  resorcin,  antipyrin,  substances  belong- 
ing to  the  digitalis  group,  and  serpent  venom,  in  small  doses 
are  active.  Thallin,  alcohol,  ether,  and  glycerine,  have  no 
action.  Essential  oils,  such  as  oil  of  turpentine,  hydrate  of 
terebene,  eucalyptol,  oil  of  chamomile  flowers  and  a  number  of 
others  have  a  remarkable  effect.  According  to  Dr.  Liebreich, 
these  substances  act  by  destroying  the  nerve-ends  and  by  irri- 
tating the  neighboring  parts,  causing  what  has  been  caDed 
"painful  ancesthesia."  Some  substances,  such  as  cocaine,  do 
not  cause  painful  anjesthesia,  and  are  followed  by  contraction 
of  the  vessels,  whereas  substances  that  cause  painful  amesthe- 
sia  lead,  on   the   contrary,  to   vascular  dilation.     Substances 


LOCAL   ANESTHETICS.  29 

causing  painful  anaesthesia  have  a  caustic  action,  particularly 
hydroquinine.  This  anaesthetic  and  caustic  action  is  also  ob- 
served in  distilled  water,  the  action  of  which,  on  the  nerves,  is 
already  known.  In  general  a  very  great  number  of  substances 
produce  local  anaesthesia,  but  in  their  application  to  man  it  is 
necessary  to  examine,  first,  whether  they  act  as  caustics,  pro- 
ducing painful  anaesthesia.  The  objections  to  some  of  these 
agents  are,  that  when  the  application  has  been  made,  and  the 
operation  performed  without  pain,  there  is  a  reaction,  if  too 
freely  used,  by  the  return  of  the  blood,  with  great  force,  press- 
ing upon  the  nerves;  or  there  may  be  a  partial  death  of  the  parts 
if  frozen  completely,  so  that  the  pain  following  is  intense  and 
prolonged.  At  times  there  is  loss  of  the  parts,  also  profuse 
hemorrhages.  Still,  with  all  these  drawbacks,  they  can  at  times 
be  employed  with  success,  when  no  other  agents  are  at  hand. 

Carbolic  acid,  painted  over  the  surface  of  the  skin,  or  ap- 
plied to  a  nerve  exposed  in  a  tooth,  will  cause  it  to  become 
white  and  lose  its  sensibility,  producing  local  anaesthesia.  In 
1772,  Percival  introduced  carbonic  acid  as  a  local  anaesthetic  to 
relieve  pain,  and  the  late  Professor  Dewees,  of  Philadelphia, 
recommended  it  in  carcinoma  uteri,  also  in  cancer  of  the  rec- 
tum. In  1856,  the  late  Professor  Simpson  improved  the  appa- 
ratus so  as  to  apply  it  with  more  efiiciency. 

The  pain  felt  duringthe  extraction  of  a  tooth  is  lessened  by  the 
employment  of  rapid  respiration  (Bonwell's  method),  violent 
muscular  effort,  or  vibration.  A  still  more  powerful  adjunct 
is  electricity  applied  along  the  course  of  the  nerves.  The  Far- 
adaic,  or  interrupted  galvanic  current,  was  at  one  time  em- 
ployed in  this  city  to  produce  a  local  anaesthesia.  This  em- 
ployment of  electricity  has  been  revived  by  Dr.  I.  Corning,  of 
New  York,  by  first  perforating  the  skin  with  needles,  with  the 
instrument  of  "Baunschiedt,"  and  then  applying  over  the  sur- 
face a  sponge  electrode,  saturated  with  a  two  per  cent,  solution 
of  hydrochlorate  of  cocaine.  This  should  be  kept  connected 
with  the  battery  from  three  to  four  minutes,  and  be  of  sufficient 
intensity  to  cause  a  slight  sensation  of  heat.  It  has  been  sug- 
gested that  the  method  can  be  made  more  efficient,  if  the  sur- 
face be  rendered  bloodless  by  the  pressure  of  Esmarch's  bandage. 


30 


ABTIFICIAL  ANESTHESIA. 


CHAPTER    III. 

Coca  Plant,  Leaves — Preparations,  more  especially  the  Wine  made 
from  the  Leaves,  also  from  the  Active  Principle — Cocaine :  Its 
Action  as  a  Stimulant  of  the  Nervous  System  and  Ketarder  of 
Metamorphosis — Cocaine  and  its  Salts,  Solutions,  Tests  of  Purity, 
Solution  in  Camphor  Water,  etc — The  Amount  Manufactured. 

Erythroxylon  Coca ;  Folia  Cocce.      The  Leaves.      Nat.  Order  :  \ 
Erythroxylacece.     Lamark.  U.  S.  P.     The  coca  is  a  small  tree 
Plate  1— (Figs.  1-13).* 


4  to  6  feet  high,  indigenous  to  the  mountains  of  Peru  and  Bo- 
livia, and  cultivated  in  both  these  countries  on  the  eastern 

♦The  entire  illustration  is  that  of  branch  with  young  foliage  and  flowers.  No  2, 
entire  flower  ;  between  2  and  3,  petal  ;  3,  petal  ;  4,  flower  with  petals  removed  ;  5, 
calyx  and  pistil ;  6,  vertical  section  ovary  ;  7  and  8,  transverse  sections  ovary  ;  9  and 
10,  fruit;  11,  transverse  section  of  fruit;  12,  section  of  stem  with  leaves  removed; 
13,  apex  of  leaf. 


COCAINE.  31 

slope  of  the  Andes,  in  damp,  warm  valleys.  The  leaves  are 
chewed  by  the  natives  to  satisfy  hunger,  to  strengthen  the  weak, 
to  stimulate  the  nerves  and  to  remove  depression  or  melan- 
choly. The  extract  obtained  by  alcohol  of  21°  and  56"  has  all 
the  gummy  and  resinous  principles  of  the  coca  leaf,  as  well  as 
the  fatty,  nitrogenous  principles,  the  tannin,  the  chlorophyl 
and  the  alkaloid.  It  is  this  extract  which  represents  best,  and  ^ 
in  exact  proportion,  the  consiiiueni  principles  of  coca.  ^r^ 

Like  tea  and  coffee,  coca  is  used  in  nervous  headache,  and  as 
a  substitute  for  opium  in  opium  habit.  A  similar  use  has  sug- 
gested itself  in  the  treatment  of  alcoholism,  spermatorrhoea, 
generative  debility,  granular  pharyngitis,  and  relaxation  of  the 
muscles  of  the  larynx,  pharynx  and  middle  ear. 

There  is  a  wine  of  coca  made  from  Ae  fresh  and  dry  leaves 
with  sherry  or  claret  wine. 

\¥ine  of  Coca,  from  Cocaine. 

We  have  been  disappointed  in  the  results  of  the  administra- 
tion of  the  ordinary  wine  of  coca  in  the  market,  audit  has  been 
suggested  the  preparing  of  this  wine  so  that  it  will  contain  a 
fixed  proportion  of  cocaine,  and  at  the  same  time  be  free  from 
the  tannin,  resin,  and  other  inert  or  deleterious  substances  pre- 
sent in  the  leaves. 

To  a  good-bodied  wine — not  sherry — add  five  grains  of  the 
hydrochlorate  of  cocaine  to  the  pint,  the  dose  being  half  a  wine- 
glassful,  which  will  contain  about  a  twelfth  of  a  grain,  repeated 
at  each  meal.  We  have  found  this  wine  of  special  value  as  a 
tonic  to  the  vocal  apparatus,  or  in  cerebral  hypersemia,  the  re- 
sult of  excessive  mental  or  physical  disturbance.  It  has  also 
been  found  useful  in  hysteria,  and  as  a  tonic  and  stimulant  in 
weakened  and  exhausted  nervous  system. 

Therapeutical  Uses  of   Coca  L<eaves. 

We  have  employed  the  coca  and  found  it  useful,  first,  in  our 
own  case,  and  also  in  that  of  several  of  our  patients.  The  first 
effect  of  our  experiments  with  the  elixir  and  fluid  extract  of 
coca  in  full  doses  was  a  somewhat  irregular  muscular  action  or 
co-ordination,  and  if  given  in  large  doses  walking  becomes  ir- 


32  ARTIFICIAL   ANAESTHESIA. 

regular.  Soon  after  the  moderate  dose  there  comes  a  feeling  of 
comfort,  and  as  the  effects  pass  o(f  there  is  a  slight  irregularity 
of  the  rhythm  of  the  heart ;  this  is  followed  after  a  certain  time, 
if  taken  at  night,  by  a  pleasant  sleep.  If  taken  through  the 
day  and  not  immediately  before  meals  by  a  person  with  no  de- 
sire for  food,  or  if  taken  after  meals,  it  passes  off"  before  the 
next  regular  meal  and  the  appetite  is  not  affected.  The  wine 
Avas  the  first  preparation  recommended  to  us,  but  after  using  that 
made  in  this  city  with  sherry  wine,  we  found  it  objectionable  to 
certain  of  our  patients,  causing  headache  and  dyspeptic  symp- 
toms; so  that  in  .Jefferson  Medical  College  Hospital  we  resorted 
to  a  preparation  of  the  elixir  in  doses  of  sixty  drops,  three 
times  a  day.  One  week  after  a  patient  with  tinnitus  reported 
the  noises  were  much  less,  throat  less  irritable,  able  to  ob- 
tain a  view  of  the  vocal  cords,  which  were  found  white,  but  still 
somewhat  relaxed  in  the  act  of  phonation.  The  only  objection 
to  its  continued  use  in  this  form  was  the  constipation.  This 
constipation,  it  is  stated  by  our  patients,  does  not  follow  the 
use  of  the  elixir  made  with  glycerine,  or  the  lime-water  in- 
fusion. Still  the  peculiar  tannin  which  it  contains  is  one  of 
its  important  agents,  and  should  not  be  omitted,  as  it  unites 
with  the  active  principle  ;  therefore  it  is  best  to  use  the  active 
preparation,  for  the  constipation  can  be  readily  obviated  by 
adding  a  mild  laxative. 

In  man,  the  coca  suspends  the  appetite  for  food  for  some 
hours,  and  at  the  same  time  greatly  increases  the  muscular 
strength  and  endurance.  The  celebrated  traveler,  "Tschudi," 
found,  when  coca  leaves  were  taken  in  infusion,  it  conferred  a 
singular  immunity  from  suffering,  and  prevented  the  hemor- 
rhages which  were  apt  to  occur  in  the  elevated  passes  of  the 
Andes,  some  of  which  are  17,000  feet  high.  The  experiments 
of  Mason,  of  Boston,  upon  himself,  with  the  fluid  extract  of  coca, 
confirm  some  of  the  above  observations.  If  used  to  excess, 
coca  deranges  the  digestion  and  causes  habitual  constipation. 


COCAINE.  33 

Cocaine  and  Its  Salts. 

In  1855,  Gaedeke  discovered  in  coca  an  alkaloid  to  which  he 
gave  the  name  erythroxyline ;  but  this  principle  was  first 
thoroughly  studied  by  Dr.  Albert  Niemann,  from  whom  it  re- 
ceived the  name  cocaine,  and  was  an  anaesthetic,  but  used  in 
the  eye  by  Dr.  Karl  Koller,  of  Vienna.  ^  » 

^^"^  The  hydrated  alkaloid  cocaine  is  in  light,  white,  spongy  \\ 
fragments,  or  in  light  amorphous  powder,  very  much  like  mag- 
nesia. It  is  not  perfectly  white,  but  very  nearly  so.  It  is 
nearly  insoluble  in  water,  but  very  soluble  in  acids,  giving  so- 
lutions that  are  not  quite  colorless.  When  a  very  small  parti- 
cle is  laid  upon  the  tongue,  and  the  tongue  then  held  against 
the  roof  of  the  mouth,  a  moderately  bitter  taste  is  perceived. 
In  a  few  seconds  more  the  bitterness  gives  place  to  numbness 
and  insensibility  of  the  surfaces,  as  though  scalded  by  hot 
liquid,  except  that  there  is  no  pain.  This  numbness  increases 
for  a  few  minutes,  and  then  diminishes  slowly,  and  disappears 
in  from  ten  to  twenty  minutes  in  proportion  to  the  quantity  ap- 
plied. The  hydrochlorate  of  cocaine  is  an  almost  white  crys- 
talline powder,  though  the  fragments  of  crystals  are  so  small 
that  it  appears  to  be  an  amorphous  powder,  even  under  a  glass 
of  low  power.  The  powder  when  dry  is  loose  and  mobile,  but 
when  exposed  to  damp  air  becomes  a  little  damp  and  clammy, 
although  it  does  not  appear  to  be  deliquescent.  It  is  soluble 
in  all  proportions  in  hot  water,  in  alcohol,  and  in  some- 
what less  than  half  its  weight  of  water  at  ordinary  tempera- 
tures. Its  solutions  are  not  always  colorless,  but  appear  to  be  ^- 
\'  nearly  so  when  seen  in  small  vials,  even  up  to  the  strength  of  y/!^^ 
20  per  cent.  Solutions  of  50  or  60  per  cent,  strength  are,  how- 
ever, even  in  small  vials,  of  a  greenish-yellow  tint.  The  solu- 
tions are  neutral  to  test-paper.  When  tested  with  solution  of 
chloride  of  barium  they  give,  after  a  moment  or  two,  the  faint- 
est cloud  (limit  of  sulphates).  With  test  solution  of  oxalate  of 
ammonium  the  result  is  negative  (absence  of  lime).  When  the 
salt  is  burnt  on  a  platinum  surface,  there  is  merely  a  trace  of 
residue  (limit  of  inorganic  matter),  and  the  spot  moistened 
with  water  scarcely  affects  the  color  of  neutral  litmus  paper 
(limit  of  inorganic  alkalies). 

2* 


34  ARTIFICIAL   AXiESTIIESIA. 

According  to  Dr.  Niemann,  the  discoverer  of  cocaine,  the  al- 
kaloid, when  heated  in  a  tube,  decomposes,  with  the  evolution 
of  a  dense  sublimate  of  benzoic  acid.  Wohler  and  Losson 
found,  upon  heating  cocaine  several  hours  in  a  sealed  glass 
tube  with  concentrated  hydrochloric  acid,  that  the  cocaine  re- 
solved itself  into  benzoic  acid,  methyl  alcohol  and  ecgonine. 

Cocaine  aud  its  Impurities. 

The  presence  of  hygrine  and  ecgonine  in  the  hydrochlorate 
of  cocaine  may  be  detected  by  treating  the  salt  with  cold  con- 
centrated sulphuric  acid.  If  the  salt  is  pure,  the  result  is  a 
completely  colorless  solution.  The  impurities  will  stain  the 
solution. 

The  Instability  of  Cocaine. 

The  great  instability  of  cocaine  is  now  well  known,  the 
simple  contact  of  the  free  alkaloid  with  water  being  sufficient 
to  decompose  it.  (Paul  and  Flieckegen.)  The  hydrochlorate, 
which  is  much  more  stable,  should  be  absolutely  neutral ;  vola- 
tilized completely,  forms  a  colorless  or  slightly  turbid  solution 
in  water,  gives  a  colorless  solution  with  strong  sulphuric  acid, 
and  should  not  reduce  permanganate  of  potassium  immedi- 
ately.    (Beckurts.) 

Cocaine  has  the  composition  Ci^HjiNO^.  It  is  slightly  soluble 
in  water,  more  so  in  alcohol  and  freely  in  ether.  In  addition 
to  it  coca  leaves  contain  cocatannic  acid,  wax  and  a  pale,  yel- 
low, oily  volatile  alkaloid,  hygrine.  Ecgonine,  which  is  obtained 
by  the  action  of  hydrochloric  acid  on  cocaine,  has  the  compo- 
sition C9H15NO3,  and  is  insoluble  in  ether. 

The  Hytli'ochlorate  of  Cocaine  in  Solution  of  Cam- 
phor-Water. 

While  in  Glasgow,  Scotland,  attending  the  session  of  the 
British  Medical  Association,  Dr.  Barr,  the  distinguished  otolo- 
gist, informed  us  that  McMillan,  the  pharmacist,  had  made 
the  solutions  of  the  hydrochlorate  of  cocaine  with  camphor- 
water,  and  had  found  it  sufficient  to  prevent  the  formation  of 


COCAINE.  35 

fungi.  He  had  found  it  valuable  in  affections  of  the  nose  and 
ear,  and  had  used  it  both  before  and  after  operation  in  a  five 
per  cent,  solution  applied  with  a  brush. 

Dr.  Geisel's  test  for  cocaine  is  potassium  permanganate, 
producing  a  permanganate  salt,  and  when  heated  there  is  a 
distinct  odor  of  bitter  almonds. 

Chloride  of  gold  produces  a  distinct  precipitate  of  small 
fern  frond-shaped  crystals  arranged  in  stellate  groups.  A  so- 
lution of  iodide  of  potassium  and  picric  acid  produces  precipi- 
tates of  color,  etc.,  which  are  peculiar  to  cocaine.  The  physio- 
logical tests  are  its  anaesthetic  influence  on  the  eye,  dilatation  of 
the  pupil  and  benumbing  sensation  on  the  tongue. 

To  show  the  enormous  amount  of  cocaine  and  its  salts  made 
and  sold  by  one  manufacturing  chemist,  it  is  stated  by  Dr. 
Squibb,  of  New  York,  in  the  Ephemeris  for  October,  1889,  p.  987 
(a  journal  which  he  publishes),  that  he  has  used  since  his  last 
report  (January,  1887)  238  bales  of  coca;  total,  41,858  pounds. 
This  was  manufactured  into  hydrochlorate  of  cocaine  by  his 
process  on  p.  908,  January  number  of  Ephemeris  issue,  and 
gave  a  total  yield  as  sold  in  stock  of  922,917  grains,  or  131 
pounds,  13J  ounces.* 

*  Crttdb  Cocaine. — (From  the  Ephemeris,  vol.  iii,  J5o.  4, 1889). — It  Is  there  stated 
that  the  importation  of  coca  leaves  into  this  country  and  Eurojje  for  the  manufacture 
of  cocaine  is  nearly  at  an  end.  For  more  than  a  year  past  crude  or  raw  cocaine  has 
been  sent  from  Peru.  During  1888  it  improved  in  quality,  reaching  90  to  96  per 
cent.  Some  idea  of  the  very  large  quantities  produced  may  be  had  from  the  circum- 
stance that  one  maker  has  a  singlo  contract  with  a  European  house  for  70  kilos 
or  about  154  pounds  per  month. 

The  test  for  pure  cocaine  (Stockman's),  or  pure  hydrochlorate  of  piirs  cocaine  is, 
that  when  heated  with  strong  hydrochloric  acid  in  a  sealed  glass  tube,  in  the  water 
bath,  it  splits  up  into  its  components  without  any  change  of  color,  except  a  very  light 
yellow  tint  (from  the  HCI).  When  isatropylococine  is  so  treated,  it  splits  up  into 
ecgonine  and  a  brown  oily-looking  body,  which  is  decomposed  isatropic  acid. 

Cocaine  salts  are  now  made  synthetically  on  a  large  scale. 


36  ARTIFICIAL  ANESTHESIA. 

CHAPTER    IV. 

Experiments  with  Cocaine  on  Animals  and  Men. 

The  Pliysiological  Action  of  Cociiiiie  upon  the  Ani- 
mal System,  more  esi»ecially  upon  Dogs. 

Through  the  courtesy  of  Professor  Reichert,  of  the  Uni- 
versity of  Pennsylvania,  the  following  experiments  were  per- 
formed in  his  laboratory  May  14,  1889: 

A  dog,  weighing  8  pounds,  was  injected  with  1\  grains  of 
Merck's  cocaine.  Pulse  172,  temperature  R.  38.9,  being  at  the 
rate  of  2  centigrammes  per  kilo.  Soon  after  he  became  rest- 
less, moving  his  tongue  in  and  out  of  his  mouth,  showing  an 
extra  secretion  of  saliva.  Then  followed  jerking  movements 
of  the  muscles,  more  especially  of  the  neck  and  head,  being 
unable  to  stand  on  his  feet,  as  though  intoxicated.  The  pupils 
became  dilated,  balls  very  prominent  and  hard  from  in- 
creased intraocular  pressure.  In  the  course  of  ten  minutes 
or  more  convulsions  supervened.  Temperature  increased 
to  39.4°,  pulse  to  124.  After  15  minutes  there  were  both 
clonic  and  tonic  convulsions.  His  bodily  movements  were 
in  a  circle,  swaying  his  head  from  side  to  side.  This  mo- 
tion of  the  head  continued  for  several  hours — even  after  the 
movement  of  the  limbs,  which  had  been  lost,  had  been  re- 
gained. A  pinch  was  felt,  showing  no  want  of  reflex  excita- 
bility. When  fully  under  the  influence  of  the  cocaine,  sight 
and  hearing  seemed  unimpaired  until  convulsions  set  in.  At 
times  there  was  great  difiiculty  in  co-ordination,  but  there 
was  no  up  and  down  motion  of  the  head,  and  the  convulsive 
motions  were  almost  always  rotary  and  to  and  fro. 

Second  Experiment. — Weight,  IGj  pounds,  pulse  120,  tem- 
perature 38.9°.  Dose  for  his  weight,  10  centigrammes.  A  much 
more  timid  animal  than  the  first,  and  after  15  minutes  became 
very  restless,  with  his  head  at  times  between  his  feet,  having  a 
weaving  motion,  his  mouth  making  a  snapping  movement.  The 
grain  and  a  half  of  cocaine  which  he  received  by  injection  did 
not  appear  to  produce  the  desired  intense  physiological   ef- 


COCAINE.  37 

fects,  so  that  IJ  grains  extra  was  introduced  over  the  spine. 
Now  his  brain  became  evidently  very  much  affected,  and  his 
delirium  overcame  his  timidity.  When  under  great  excite- 
ment he  began  by  running  around  the  laboratory,  battering 
himself  at  intervals  against  anything  that  was  in  his  way. 
Respiration  increased,  causing  him  to  pant.  Ears  were 
thrown  back,  eyes  protruding,  balls  hard,  pupils  dilated,  but 
not  to  the  same  degree  as  the  first  animal. 

It  was  early  noticed  that  heat  is  increased  in  the  human 
body  by  the  use  of  cocaine.  In  1887,  Mosso,  of  Turin,  dem- 
onstrated by  experiment  that  this  drug  possessed  a  remarkable 
power  over  the  bodily  temperature,  raising  it  independently  of 
convulsions  or  section  of  the  spinal  column,  and  this  is  owing, 
according  to  Mosso,  to  direct  changes  in  the  tissue,  or  the  ac- 
tion of  cocaine  on  the  heat  centres  supposed  to  exist  in  the 
spinal  cord.  These  facts  in  regard  to  the  section  of  the  spinal 
cord  have  not  been  confirmed  by  Professor  Eeichert  (see  p.  53). 
In  the  experiments  of  Dr.  Hare,  upon  dogs  only,  one  is  noted  as 
having  violent  convulsions.  A  portion  of  cocaine  employed 
by  him  varied  from  J  a  grain  in  a  dog  weighing  9  pounds, 
to  f  of  a  grain  to  a  dog  weighing  17  pounds.  In  every  in- 
stance the  cocaine  was  injected  into  the  jugular  vein.  Ani- 
mals, like  human  beings,  are  affected  differently. 

The  following  are  the  most  recent  conclusions  of  Professor 
Reichert  on  the  action  of  cocaine  on  animal  heat  functions: 
"There  are  comparatively  few  drugs  known  to  therapeutists 
that  are  capable  of  causing  a  notable  increase  of  bodily  tem- 
perature, and  even  of  these  a  large  percentage  is  supposed  to 
owe  this  activity  largely  or  wholly  to  accompanying  motor 
disturbances.  It  is  at  least  a  curious  circumstance,  that  all 
poisons  which  appreciably  increase  temperature  are  pro- 
nounced convulsants.  Among  the  most  decided  of  the  physio- 
logical actions  of  cocaine  is  that  of  producing  a  rise  of  tem- 
perature which,  even  in  moderate  doses,  may  be  quite  remark- 
able. Von  Anrep*  states  that  the  temperature  of  the  skin 
was  always  decidedly  increased  from  the  first,  while  the  rectal 

*Pfluger'e  Arcbiv.,  Bd.  XXI.  8.  68. 


38  ARTIFICIAL  ANiESTHESIA. 

temperature  at  the  same  time  remained  unaltered,  or  was  de- 
creased from  0.5°  to  1°  C,  the  latter  rising,  however,  during 
the  convulsions,  to  a  similar  extent.  Dauini  (quoted  by  An- 
rep)  notes  that  a  rise  amounting  to  1°  C.  occurs  during,  and  is 
dependent  upon,  the  convulsions.  Mosso  *  always  observed  a 
rise,  amounting  to  as  much  at  times  as  3.]°  C,  and,  contrary 
to  Danlni,  being  independent  of  convulsions,  since  it  occurred 
in  animals  rendered  motionless  by  curare.  Hare,t  in  ten  ex- 
periments in  which  the  drug  was  injected  intravenously, 
records  a  rise  varying  from  2°  to  7.5°  F.  (1.11°  to  4.17°  C),  the 
average  being  4.14°  F.  (2.3°  C).  Dose  for  dose  the  action  is 
more  powerful  and  prompt  when  intravenously  injected  than 
when  hypodermatically." 

In  Reichert's  studies,  comprising  about  twenty  experiments 
on  dogs,  a  marked  increase  was  always  noted.  '"  In  all,  Merck's 
hydrochlorate  of  cocaine  was  used  and  injected  hypodermati- 
cally. The  fatal  dose  in  dogs  is  about  0.03  gram  per  kilo. 
Doses  of  0.0025  gram  per  kilo  elicit  fairly  well-defined  symp- 
toms of  cocaine  poisoning,  dilation  of  the  pupils,  restlessness, 
salivation,  increased  frequency  of  respiration,  more  frequent 
and  forcible  pulse,  increased  temperature,  etc.  With  such 
doses  the  temperature  is  increased  about  from  0.2°  to  0.5°  C. 
Doses  of  0.01  gram  per  kilo  cause  a  rise  of  from  1°  to  2°  C. 
Doses  of  0.02  gram  per  kilo,  a  rise  of  from  2°  to  4°  C.  The  in- 
crease is,  however,  not  always  in  proportion  to  the  dose,  rela- 
tively small  doses  sometimes  causing  a  considerable  rise,  and 
vice  versa.  The  potency  of  cocaine  in  this  respect  is  alto- 
gether remarkable,  and  places  the  drug  in  the  foremost  rank 
of  pyrogenic  agents;  indeed,  so  powerful  is  it  at  times  that 
animals  suffer  from  heat  dyspnoea.  Moreover,  the  action  is  one 
of  notable  permanency,  the  temperature  after  large,  but  sublethal 
doses,  remaining  above  normal  for  six  or  eight  hours  or  more. 

"  Following  the  rise  of  temperature,  and  subsequent  return  to 
the  normal,  a  fall  ensues,  which,  even  after  moderate  doses, 
lasts  for  some  hours. 

*Archiv.  f.  Exp.  Path.  u.  Pbar.,  Bd.  XXIII.  8.  153. 
t  University  ^fedicnl  Magazine,  Vol.  I.,  p.  358. 


COCAINE.  39 

"  The  results  of  my  experiments  are  not  in  accord  with  Von 
Anrep's  statements,  above  referred  to,  since  in  every  instance 
a  marked  rise  of  temperature  occurred,  from  the  first  simulta- 
neously in  the  rectum  and  axilla  (skin),  the  thermometers  at 
both  points  of  observation  in  our  experiments  being  placed  in 
position  before  giving  the  drugs,  being  allowed  to  settle,  and 
not  being  removed  during  the  entire  time  of  observation.  The 
alterations  in  temperature  progressed  joaWjoassM  in  both  cases. 
The  rectal  temperature  rises  more  rapidly  than  that  of  the 
skin,  this  being  due  to  a  large  extent,  if  not  v/holly,  to  the 
quicker  reaction  of  the  thermometer  in  the  former  position. 
The  thermometers  used,  when  placed  in  the  rectum,  settle  in 
from  three  to  five  minutes,  but  from  ten  to  fifteen  minutes  are 
required  in  the  axilla,  although  the  thermometers  were  iden- 
tical in  make  and  sensitiveness."  We  cannot  give  the  full 
details  of  Dr.  Eeichert's  experiments,  but  he  showed  that  a  rise 
in  temperature  does  not  occur  after  section  of  the  spinal  cord. 

We  have  shown  by  the  above  experiments  on  dogs,  the  action 
of  cocaine.  The  accompanying  trace  (Plate  2,  p.  40),  of  the  de- 
tached heart  of  a  frog,  being  circulated  with  solution  of  cocaine 
1  in  2000,  shows  the  power  of  this  drug  as  a  cardiac  depressant 
in  cold-blooded  animals,  depressing  the  beat,  and  finally  arrest- 
ing the  heart  in  diastole.     (Buxton.) 

On  the  Action  of  Cocaine  on  tlie  Eye. 

On  September  15,  1884,  Dr.  Karl  Koller,  of  Vienna,  first 
exhibited  to  the  profession  the  anaesthetic  effects  of  cocaine  on 
the  eye.  When  introduced  into  the  eye,  it  causes  local  anses- 
thesia,  with  dilatation  of  the  pupil,  paralysis  of  accommoda- 
tion, slight  lachrymation,  and  enlargement  of  the  palpebral 
fissure. 

When  injected  into  the  back  of  the  orbit,  it  causes  protrusion 
of  the  eyeball.  Its  effects  appear  to  be  due  to  stimulation  of 
the  peripheral  ends  of  the  sympathetic.  Subcutaneous  injec- 
tions also  produce  local  anaesthesia  at  the  point  of  application, 
so  that  subsequent  irritation  at  that  spot  produces  no  sensation 
in  man  and  no  reflex  action  in  animals.  When  taken  inter- 
nally, it  appears  to  have  in  small  doses  a  stimulating,  and  in 


40 


ARTIFICIAL    ANAESTHESIA. 


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COCAINE.  41 

large  doses  a  paralyzing  action  on  the  nerve  centres.  It  affects 
first  the  cerebral  hemisphere,  next  the  medulla,  and  afterwards 
the  spinal  cord. 

The  writer  has  performed  numerous  experiments  on  himself 
and  others  to  determine  the  action  of  the  alkaloid  cocaine  and 
its  chief  salt,  the  hydrochlorate. 

In  moderate  doses  of  the  hydrochlorate  it  can  be  adminis- 
tered in  from  one-fifth  to  even  one-quarter  of  a  grain  every 
hour,  until  the  patient  is  relieved,  or  the  peculiar  constitutional 
symptoms  show  themselves;  these  doses  acting  as  a  stimulant 
on  the  peripheral  ends  of  the  sympathetic.  In  larger  doses  it 
has  an  action  on  the  nerve  centres,  aff'ecting  first  the  cerebrum, 
next  the  medulla,  afterwards  the  spinal  cord.  If  employed  in 
still  larger  doses  there  is  intense  exhilaration,  or  intoxication, 
more  or  less  loss  of  consciousness,  followed  by  palpitation  and 
even  death,  although  this  is  rare. 

The  average  therapeutic  dose  has  not  yet  been  deter- 
mined. 

On  tlie  Hypodermic  Employnient  of  tlie  Hydro- 
chlorate of  Cocaine. 

To  prevent  syncope  and  nausea,  while  using  the  hydro- 
chlorate of  cocaine  in  subcutaneous  injections,  the  patient 
should,  in  almost  every  instance,  recline.  This  is  absolutely 
necessary  if  the  patient  is  anaemic  or  very  feeble.  Cerebral 
anaemia  may  be  produced  in  certain  individuals  by  the  use 
of  even  ten  drops  of  a  two  per  cent,  solution. 

The  strength  of  the  solutions  for  local  use  varies  as  follows  : 
From  two  to  twenty  per  cent. — that  is,  one  grain  to  every  hun- 
dred grains  of  distilled  water — but  it  is  wiser  to  begin  with  the 
weaker  solution.  To  prevent  alterations  or  the  formation  of 
fungi  in  these  solutions  we  have  to  resort  to  certain  antiseptic 
agents,  which  are  as  follows :  Boracic  acid,  two  to  four  grains 
to  the  ounce.  Salicylic  acid,  a  quarter  or  a  half  a  grain  to  the 
ounce  of  solution.  Two  centigrammes  of  bichloride  of  mercury 
in  one  hundred  grains  of  water. 

The  great  advantage  in  the  hypodermic  use  of  the  injection 
of  the  hydrochlorate  of  cocaine,  in  this  form,  is  its  rapidity 


42  ARTIFICIAL   ANAESTHESIA. 

of  action,  making  its  impression  very  promptly,  say.  in  from 
three  to  five  minutes. 

Peculiar  effects:  a  nervous  thrill  or  tingling  sensation,  in- 
crease of  pulse,  dryness  of  the  tongue,  relief  of  pain  or  gastric 
disturbance,  sensation  of  fulness  in  the  head  or  heat  of  the 
face,  at  times  producing  wakefulness,  followed  by  frontal  head- 
ache; in  other  cases  there  is  dilatation  of  the  pupil,  with  a 
tendency  to  sleep,  the  patient  awaking  in  his  ordinary  con- 
dition of  mind.  If  larger  doses  are  required,  the  symptoms  are 
similar  in  character,  only  increased  in  intensity,  great  mental 
excitement,  increased  irregularity  in  rhythm  or  force  of  the 
heart,  insomnia,  or  being  unable  to  sleep,  and  invariably 
headache  the  following  morning. 

Fatal  Dose  of  Hydroclilorate  of  Cocaine. 

The  fatal  dose  is  usually  from  eighteen  to  twenty  grains,  but 
from  idiosyncrasy  or  peculiarity  of  constitution,  a  much  smaller 
dose  may  produce  fatal  symptoms.  Dr.  Hammond,  of  New 
York,  took  very  much  larger  doses.  Before  the  last  injection, 
the  pulsations  of  the  heart  were  140  to  the  minute,  and  char- 
acteristically irregular.  He  found  his  mind  passing  beyond 
his  control,  and  he  was  becoming  an  irresponsible  agent.  He 
lost  all  consciousness  half  an  hour  after  administering  the  last 
dose,  remaining  so  until  nine  o'clock  next  morning,  when  he 
awoke  with  an  intense  headache  with  a  great  deal  of  cardiac 
and  respiratory  disturbance. 

No  marked  influence  appeared  to  be  exercised  upon  his 
spinal  cord  or  upon  the  ganglia  at  the  base  of  the  brain. 

There  were  no  disturbances  of  sensibility  (no  anaesthesia,  no 
hypersesthesia),  and  no  interference  with  mobility  except  that 
some  of  the  muscles,  especially  those  of  the  face,  were  sub- 
jected to  slight  twitchings. 

In  regard  to  sight  and  hearing  he  noticed  that  both  were 
affected ;  but  that  while  the  sharpness  of  vision  was  decidedly 
lessened,  the  hearing  was  increased  in  acuteness.  At  no  time 
were  there  any  hallucinations. 

(1)  The  exciting  action  of  cocaine  on  the  brain  is  extremely 


COCAINE.  4.5 

prominent  among  its  physiological  peculiarities, — much  more 
so  than  its  ana3sthetic  influence. 

(2)  Montegazy's  statements  we  look  upon  as  a  mass  of  gross 
and  utterly  inexcusable  exaggerations. 

(3)  The  first  noticeable  effect  on  the  lower  animals  is  rest- 
lessness, gradually  increasing  to  more  or  less  intense  excite- 
ment. 

(4)  In  animals  the  cerebellum  is  more  or  less  affected. 

(5)  Chloral  is  certainly  antagonistic — so  with  chloroform, 
also  ether— during  anassthetic  stage,  but  not  during  its  primary 
stage  of  excitement. 

(6)  There  is  some  evidence  to  indicate  that  the  semi-circular 
canals  are  affected,  as  shown  by  the  vertiginous  movements. 

(7)  The  convulsions  seem  to  be  both  of  cerebral  and  spinal 
origin,  but  chiefly  cerebral. 

(8)  The  motor  or  sensory  nerves  do  not  seem  to  be  affected 
until  late  in  the  poisoning. 

(9)  The  action  on  circulation  is  complex :  pneumogastric 
nerves  primarily  stimulated,  secondarily  depi-essed.  Blood 
pressure  similarly  affected.  Therapeutic  doses  probably  act 
as  circulatory  stimulant. 

(10)  The  pupils  in  all  of  the  experiments  were  dilated  and 
intra-ocular  pressure  increased.  We  have  never  noticed  any 
injurious  effects  on  animals  in  any  way  after  using  non-lethal 
doses.  They  naturally  suffer  some  after-depression  because  of 
the  intense  mental  and  muscular  excitement  during  the  action 
of  the  poison. 

(11)  Bodily  temperature  is  increased. 

(12)  Pupils  dilated,  and,  in  dogs,  intra-ocular  pressure  in- 
creased. 

(13)  Tissue  metamorphosis,  as  is  indicated  by  Dr.  Reichert's 
experiments,  is  probably  increased. 

(14)  The  fatal  dose  for  animals  is  about  0.03  grammes  per 
kilo  of  body-weight.  The  fatal  dose  for  man  varies  within 
very  wide  limits. 

(15)  It  is  claimed  that  it  at  times  interferes  with  the  healing 
oY  the  wound  after  operations,  and  to  be  less  efEcient  on  other 
membranes  than  the  conjunctiva. 


44  ARTIFICIAL   ANESTHESIA. 


CHAPTER  V. 

Cocaine  Inebriation  and  Habit — Treatment — Deaths  from  Cocaine — 
Morbid  Changes  in  Poisoning  by  Cocaine. 

The  experience  of  T.  D.  Crothers,  M.D.,  Superintendent 
Walnut  Lodge,  Hartford,  Conn.,  in  cocaine  inebriety,  is  lim- 
ited to  seven  cases.  Two  were  under  his  care  for  treatment ; 
three  came  personally  for  advice,  and  two  consulted  him  by 
letter. 

In  the  cases  under  his  care  a  correct  history  was  obtained ; 
in  the  five  cases  who  sought  advice  by  person  and  letter,  their 
own  personal  statements  were  the  chief  sources  of  informa- 
tion. In  two  cases,  statements  were  confirmed  by  others,  and 
where  such  statements  corresponded  with  the  facts  in  other 
cases,  they  were  accepted  as  probably  true.  The  following  are 
some  of  the  facts  which  appeared  from  the  history  of  these 
cases : 

Alcohol,  opium,  chloral,  bromides  and  other  narcotics  had 
been  used  more  or  less  to  excess  in  all  these  cases  before  co- 
caine was  taken.  In  four  of  these  cases,  coca  had  been  used 
for  months  before  cocaine  was  tried.  Hence,  they  were  all 
literally  drug  maniacs,  or  inebriates,  whose  special  symptom 
of  disease  is  a  morbid  impulse  for  narcotic  drugs,  which  will 
bring  rest  and  relief  to  the  organism.  He  is  also  persuaded  to 
believe  that  cocaine  inebriety,  or  coca  mania,  will  never  be- 
come prominent,  and  will  be  confined  to  a  class  of  neurotics 
who,  by  the  use  of  other  drugs,  have  prepared  the  soil  for  this 
new  drug-mania.  It  will  never  take  the  place  of  alcohol  or 
opium  in  common  use.  Its  action  is  too  uncertain  and  tran- 
sient. The  present  novelty  and  glamour  about  its  effects  will 
die  away  when  its  real  value  is  ascertained.  The  element  of 
contagion  in  these  cases  presents  a  curious  psychological 
phase  ;  thus  some  extravagant  newspaper  statement  of  the  ter- 
rible effects  of  this  drug  will  rouse  curiosity  to  test  it,  or  the 
printed  history  of  a  case  appearing  as  daily  news  draws  the 
attention  of  neurotics,  and  it  is  safe  to  say  that  a  large  per 


COCAINE.  45 

cent.  not.  only  purchase,  but  test  this  drug  on  themselves. 
Cocaine  should  not  be  used  as  a  substitute  in  breaking  away 
i'rom  the  use  of  other  narcotics.  It  should  not  be  used  in  large 
or  long-continued  doses.  It  cannot  be  used  indiscriminately. 
However  valuable  it  may  be,  there  is  a  certain  limit  to  its 
power  and  practical  use. 

The  treatment  of  cocaine  iriebriefy  is  the  same  as  that  of  alco- 
hol or  opium  cases.  Forced  abstinence  from  the  drug,  rest  and 
building  up  the  system  are  the  general  methods  pursued.  More' 
profound  degeneration  and  debility  exist  than  in  other  forms 
of  inebriety,  requiring  a  longer  time  for  successful  treatment. 

States  of  mania  and  melancholy  often  continue  for  some 
time  after  the  use  of  the  drug  is  given  up,  and  disappear  very 
slowly.  It  is  for  these  states  that  special  surroundings  and 
care  are  essential.  The  prognosis  is  always  uncertain.  The 
craving  for  drugs  that  their  effects  may  be  broken  up,  and  res- 
toration follow;  but  such  cases  generally  are  unable  to  bear 
much  exposure,  and  not  unfrequently  relapse  on  the  slightest 
temptation.  The  cases  under  our  care  recovered,  but  will  prob- 
ably relapse,  using  the  same  or  some  other  drug  in  future. 

The  Cocaine  Habit. 

The  cocaine  habit  is  yet  rare.  There  are  opium  and  mor- 
phine-eaters, who  having  heard  that  cocaine  is  an  antidote  to 
the  morphine  habit,  have  endeavored  to  cure  themselves  with 
it,  and  being  deprived  of  full  power  and  judgment  of  will, 
have  ingrafted  the  so-called  cocaine  on  the  morphine  habit. 

Dr.  Bosworth,  of  New  York,  took  between  500  and  600  grains, 
and  stopped  without  any  inconvenience. 

"  Personal  Experience,"  by  Dr.  Frank  W.  Ring— Dr.  Ring  made 
use  of  a  solution  of  hydrochlorate  of  cocaine  nightly  for  ten  months 
in  the  form  of  a  4  per  cent,  solution  applied  to  the  nasal  mucous  mem- 
brane by  means  of  an  atomizer.  About  two  grains  were  used  at  each 
application.  The  account  of  his  experience  is  exceedingly  interest- 
ing, but  we  shall  not  touch  upon  that  portion  of  his  paper  at  pres- 
ent. We  will,  however,  quote  from  him  this  paragraph,  stating  that 
during  the  ten  months  he  had  taken  more  than  600  grains  : 


46  ARTIFICIAL  ANAESTHESIA. 

"  July  9th,  I  came  to  the  conclusion  that  the  medicine  was  getting 
to  be  a  necessity ;  that  it  might  become  a  source  of  injury  to  my 
well-being,  and  I  calmly  decided  to  stop  it,  which  I  did.  The  incli- 
nation for  it  often  seizes  me,  but  I  crush  it  with  the  perfect  confidence 
that  I  shall  never  again  indulge  in  its  enchantments. 

"And  now  I  come  to  another  stage  of  my  personal  experience,  which 
I  think  is  both  interesting  and  instructive.  About  the  first  of  March 
last  I  was  attacked  by  a  violent  rhinitis,  different  in  character  and  of 
far  greater  intensity  than  any  rhinologist  I  have  consulted  has  ever 
witnessed,  and  of  a  form  not  laid  down  in  the  books.  There  was 
great  swelling  of  the  nose  and  face,  the  discharge  during  the  first 
stage  of  an  exceedingly  acrid  and  thin  fluid,  and  the  formation  sub- 
sequently of  a  membraniform  substance  not  very  unlike  that  present 
in  diphtheria,  but  very  loosely  attached  to  the  membrane,  and  show- 
ing no  disposition  to  extend  beyond  the  nasal  cavities.  Nothing  gave 
me  such  relief  as  the  application  of  a  solution  of  the  hydrochlorate 
of  cocaine  by  means  of  cotton-holders,  camel's  hair  pencils  and  atom- 
izers. Generally  I  used  a  4  per  cent,  solution,  but  not  infrequently 
one  of  10  per  cent.,  and  occasionally  one  of  20  per  cent.  I  used  it 
night  and  day  almost  continuously  during  the  montlis  of  March, 
April,  May,  June,  and  to  the  middle  of  July,  From  the  16th  of 
July  to  the  2-4th  of  August  I  was  absent  from  New  York,  at  Mackinac, 
Michigan.  During  that  period  I  had  no  rhinitis,  and  I  took  no  cocaine. 
From  the  1st  of  March  to  the  10th  of  July,  I  applied  an  average  of 
20  grains  a  day  to  the  nasal  mucous  membranes.  Of  course  nothing 
like  this  quantity  entered  the  system,  but  I  was  careful  to  carry  it 
far  enough  back  till  I  tasted  it  in  the  throat,  when  it  was  generally 
swallowed.  I  used,  therefore,  about  600  grains  a  month.  The  effects 
of  it  upon  the  system  besides  its  local  influence  were  a  slight  mental 
exhilaration,  and  sometimes  an  indisposition  to  sleep  when  I  had 
taken  more  than  my  usual  quantity.  I  was  not  confined  to  bed  a 
single  day,  nor  did  I  fail  any  day  to  discharge  all  my  professional 
duties.  I  missed  four  lectures  at  the  Medical  College,  but  that  was 
not  from  any  effect  of  the  cocaine,  but  solely  from  the  nature  of  the 
disease  with  which  I  was  affected,  and  which  prevented  me  from 
speaking  clearly. 

"On  the  IGth  of  July,  I  stopped  the  use  of  cocaine  without  the 
slightest  difficulty,  nor  did  I  resume  it  again  for  six  weeks. 

"  But  two  days  after  my  return,  August  26th,  I  had  another  of  my 
old  attacks,  and  I  again  began  the  use  of  cocaine.     From  that  date 


COCAINE.  47 

to  October  1st  I  have  used  nearly  800  grains  in  application  to  the 
nasal  mucous  membrane.  On  the  1st  of  October  I  ceased  taking  it, 
and  again  without  the  slightest  diflBculty.  On  neither  occasion  of  my 
stopping  its  administration  did  I  experience  the  slightest  craving  for 
it  or  inconTenience. 

"  So  far  as  I  know,  I  shall  not  take  it  again  unless  I  should  be  the 
subject  of  another  attack  of  rhinitis,  when  I  shall  certainly  resort  to 
it  as  the  one  agent  capable  of  aifording  relief  to  an  inflamed,  painful, 
turgid  and  altogether  uncomfortable  mucous  membrane." 

On  making  inquiry  of  Dr.  Osier,  one  of  the  attending  physi- 
cians of  the  largest  hospitals  in  Philadelphia,  as  to  how  many 
cases  he  had  ever  seen  of  cocaine  habit,  he  stated  but  one 
or  two,  and  of  opium  or  morphia  habit  during  his  term 
of  service  of  four  months,  there  were  but  four  cases.  In 
what  dose  did  he  give  cocaine  ?  As  a  rule  one-quarter  of  a 
grain  was  the  usual  dose,  and  the  strength  of  the  solution  for 
hypodermic  application  was  two  per  cent.  If  this  rule  is 
followed,  we  think  that  it  is  as  safe  as  morphine,  atropine  and- 
agents  of  a  like  character. 

In  carefully  looking  over  a  list  of  the  recent  cases  of  cocaine 
toxaemia,  by  Dr.  J.  B.  Mattison,*  of  Brooklyn,  N.  Y.,  we  find  of 
the  thirty-two  cases,  the  cocaine  was  given  in  twenty  cases  or 
employed  hypodermically  in  the  strength  of  a  four  per  cent, 
solution  up  to  a  twenty  per  cent.  Caution  should  be  exercised 
in  the  first  administration  of  the  drug,  as  in  the  use  of  all 
potent  alkaloids,  such  as  morphia,  etc.,  there  are  certain  indi- 
viduals who  are  very  sensitive  to  the  smallest  dose.  It  is  better 
to  begin  with  j^  of  *  grain,  and  gradually  increase  when  given 
internally. 

Treatment  of  Nervous  Symptoms  from  Cocaine. 

Should  nervous  symptoms  occur,  such  as  temporary  deafness, 
blindness,  loss  of  taste  or  smell,  place  the  patient  on  a  lounge 
or  sofa,  open  the  windows  and  admit  plenty  of  pure  air,  then 
employ  from  five  to  ten  drops  of  the  nitrate  of  amyl  in  capsules, 
broken  on  a  handkerchief,  to  be  inhaled  by  the  nostrils.   Should 

*  Therapeutic  Gazette,  Jan.  16,  1888. 


48  ARTIFICIAL  ANESTHESIA. 

the  patient  become  covered  with  cold  perspiration,  livid  in  color, 
apply  dry  friction  to  the  skin,  with  twenty  drops  of  aromatic 
spirits  of  ammonia,  in  water,  repeated  at  intervals.  Should 
the  patient  suffer  from  gastric  cramps,  give  a  teaspoonful  of 
compound  spirits  of  lavender,  or,  if  not  relieved,  brandy.  Use 
morphine,  hypodermically,  one-eighth  of  a  grain.  If  the  pulse 
be  irregular  or  intermittent,  with  shallow,  gasping,  irregular,  con- 
vulsive or  suspended  breathing,  artificial  respiration  should  be 
resorted  to,  with  hypodermic  injections  of  ether  or  chloroform, 
and  even  the  galvanic  battery,  to  prevent  a  fatal  result. 

Further  Treatment  of  Cases  of  Poisouing-  from 
Cocaine. 

In  cases  of  poisoning,  the  nitrate  of  amyl  is  the  best  anti- 
dote. Claude  Bernard  has  demonstrated  by  his  experiments, 
that  cocaine  in  its  action  on  the  cerebral  circulation  was  exactly 
the  antagonist  of  nitrate  of  amyl.  Under  the  effects  of  amyl, 
the  cerebral  arteries  contract,  anosmia  of  the  brain  develops, 
the  arterial  pressure  is  increased,  and  the  face  looks  pale. 
Cocaine  causes  a  dilatation  of  the  vessels  of  the  heart,  hyper- 
semia  with  diminished  arterial  pressure  sets  in  in  the  enceph- 
alon,  and  the  face  appears  flushed  and  in  a  general  state  of 
venous  congestion.  Cocaine  is  antagonistic  in  its  action  to 
ether  and  chloroform.  The  convulsive  seizures  induced  by  the 
action  of  poisonous  doses  of  cocaine  can  be  at  once  allayed  by 
the  inhalation  of  either  of  these  agents.  In  cases  of  cocaine 
poisoning  in  man,  we  therefore  recommend  that  ether  or  chlo- 
roform should  be  administered  to  allay  the  first  and  severer 
symptoms,  chloral  being  afterward  given  in  small  doses  to  keep 
up  the  effect. 

We  have  seen  symptoms  of  cocaine  poisoning  in  subjects  of 
morphia  habit  rapidly  removed  by  a  hypodermic  injection  of 
morphia,  and  in  one  case,  five  grains  of  cocaine  had  been  taken 
hypodermically  within  ten  minutes ;  and  we  have  frequently 
seen  the  same  antagonistic  effect  produced  by  a  small  quantity 
of  cocaine  in  an  overdose  of  morphia.  The  symptoms  of 
poisoning  are  controlled  by  the  use  of  ether  and  chloroform, 
which  are  both  antagonistic  to  cocaine,  and   the  symptoms 


COCAINE,  49 

often  subside  in  two  or  three  hours,  without  the  use  of  any 
antidote. 

The  Toxic  Action  of  Cocaine  in  Certain  Operations. 

It  has  been  found  that  cocaine  is  more  toxic  when  used  in 
operations  on  the  head  or  face,  than  when  used  on  other  parts 
of  the  body.  In  operations  on  the  extremities,  sixteen  minims 
of  a  five  per  cent,  solution  may  be  injected  without  unpleasant 
symptoms  arising,  except  in  the  face,  urethra  and  rectum, 
which  are,  with  the  head  and  neck,  more  sensitive  to  its  toxic 
action.  Toxic  symptoms  in  this  region  will  be  observed,  if  more 
than  one-third  of  a  grain  be  used. 

Death  from  Cocaine  in  a  Lady  with  Tuherculous 
Ulcer  of  the  Uterus. 

"  In  order  to  produce  ansesthesia,  a  Russian  surgeon  had  fifty 
grammes  of  a  five  per  cent,  solution  of  hydrochlorate  of  cocaine 
prepared ;  of  this,  thirty  grammes  were  brought  into  use,  con- 
taining exactly  twenty-four  Russian  grains  of  the  salt,  or 
twenty-three  English  grains — the  Russian  grain  is  exactly  one- 
sixteenth  of  a  gramme — six  grains  being  injected  at  a  time  into 
the  rectum.  After  the  third  of  these  injections,  it  was  found 
on  examination  that  the  part  was  still  sensitive.  A  speculum 
was  then  introduced,  the  ulcer  soaked  with  a  dry  sponge,  and 
then  the  fourth  injection  given,  making  twenty-four  grains  in 
all.  After  this  the  parts  were  tolerably  ansesthetised.  The  ulcer 
was  scraped,  and  a  tampon  saturated  with  oil  inserted.  The 
pulse  was  then  accelerated.  During  the  operation  the  patient 
groaned,  so  that  even  the  twenty-four  grains  had  not  produced 
complete  ansesthesia. 

"  After  the  operation,  Kolomnin  went  round  his  ward,  and  in 
three-quarters  of  an  hour  a  message  was  sent  to  him  that  the 
patient  was  very  low.  He  found  the  pulse  very  weak,  the  face 
and  hands  cyanotic,  and  the  respiration  labored.  He  consid- 
ered that  she  was  in  a  toxic  state,  and  used  every  means  to 
bring  her  round.  Prof.  Sushchinski  being  also  invited  to  a  con- 
sultation. Faradization,  artificial  respiration,  hypodermatic 
injection  of  ether,  administration  of  ammonia,  tracheotomy  for 
3 


50  ARTIFICIAL   ANiESTIIESIA. 

the  inhalation  of  oxygen,  stimulating  and  nutrient  enemata — 
all  were  tried,  but  without  success.  Ivolomnin  had  no  doubt 
that  death  was  due  to  cocaine." 

Dr.  W.  H.  Long,  U.  S,  Marine  Hospital  Service,  reports  in 
the  American  Lancet  the  case  of  a  man  aged  thirty-three,  to 
whose  larynx  he  applied  three  times  a  four  per  cent,  solution 
of  cocaine.  Prompt  relief  was  given,  but  three  and  one-halt 
hours  later  the  patient  was  found  unconscious;  breathing  la- 
bored ;  respirations,  twenty ;  pulse,  ninety ;  general  condition, 
one  of  profound  anaesthesia.  Diagnosis,  cocaine  poisoning. 
Several  doses  of  whiskey  were  given  subcutaneously.  In  half 
an  hour  consciousness  partially  restored,  then  gradual  and  full 
improvement  save  a  feeling  ot  great  exhaustion. 

Four  days  later  cocaine  was  again  used.  Thinking  the  for- 
mer toxic  effect  due  to  swallowing  some  of  the  solution,  and 
probable  absorption  by  larynx,  extra  precaution  was  taken  to 
have  it  expelled  and  the  pharynx  well  rinsed.  Two  applica- 
tions of  a  two  per  cent,  solution  were  made.  Relief  was  again 
complete,  but  three  and  one-half  hours  after  the  patient  was  in 
the  same  condition  as  before,  except  the  anaesthesia  not  so  pro- 
found. Frequent  injections  of  whiskey  were  again  used  with 
partial  success — could  swallow  and  answer  questions — but,  soon 
after,  he  suddenly  ceased  to  breathe.  The  heart  beat  a  short 
time  longer.  All  efforts  at  resuscitation  failed.  The  probable 
immediate  cause  of  death  was  paralysis  of  the  respiratory  cen- 
tre due  to  cocaine. 

Dr.  F.  M.  Thomas,  of  Leonardsville,  Kansas,  reported  to 
Prof.  R.  Ogden  Doremus  as  follows  : 

"  Friday  morning,  October  23d,  1885, 1  was  called  to  see  Mrs. 

,  aged  thirty-nine,  whom  the  messenger  reported  as  dying. 

I  found  her  unconscious  ;  breathing  heavily  and  irregularly ; 
pulse  thirty-five,  intermittent;  temperature  normal ;  left  pupil 
largely  dilated,  right,  natural ;  right  arm  and  lower  limbs  motion- 
less ;  face  spasmodically  drawn  upwards  towards  the  dilated  eye. 

"Spasmodic  action  of  the  left  arm  and  upper  part  of  the 
body  came  on  regularly  at  intervals  of  a  few  minutes,  during 
which  she  clutched  the  bed-clothing,  and  seemed  to  be  trying 
to  vomit.    Twice  during  my  attendance  she  ejected  small  por- 


COCAINE.  61 

tions  of  the  previous  evening's  meal.  Salivation  was  excessive ; 
retained  a  dorsal  decubitus ;  would  not  lie  on  either  side ;  heart 
seemed  almost  exhausted. 

"  I  saw  her  at  5  a.m.,  and  was  with  her  nearly  all  the  time 
until  she  expired,  apparently  completely  exhausted,  about  8.30 

A.M." 

On  inquiry,  the  doctor  learned  that  Mrs.  had  been 

freely  using  a  four  per  cent,  solution  of  cocaine  for  toothache, 
due  to  several  much-decayed  left  upper  molars.  His  diagnosis 
was  cocaine  poisoning. 

Dr.  Knabe,  of  Berlin,  records  the  case  of  a  girl,  aged  eleven, 
who  was  given  from  four  to  twelve  drops — the  exact  amount  was 
not  determined — of  a  four  per  cent,  solution  of  cocaine,  by  in- 
jection over  the  deltoid,  to  remedy  frequent  fainting  fits — she 
having  cardiac  degeneration,  sequeling  scarlatina.  In  less  than 
forty  seconds  the  girl  took  a  deep  breath,  became  deadly  pale, 
and  dropped  unconscious.     One  minute  later  she  was  dead. 

Fatal  Accident  Following  a  Hypodermatic  Injec- 
tion OF  Cocaine  (Abadie). — The  author  reported  at  a  recent 
meeting  of  the  Ophthalmological  Society  of  Paris,  the  case  of  a 
woman,  seventy -one  years  of  age,  upon  whose  eye  he  was  oper- 
ating, and  whose  death  occurred  so  soon  after  the  use  of  the 
cocaine  as  to  lead  to  the  belief  that  the  cocaine  was  somehow 
the  cause.  Instead  of  a  2  per  cent,  solution,  which  he  was  ac- 
customed to  using,  he  happened  to  employ  a  5  per  cent,  solu- 
tion, but  had  only  injected  about  three-fourths  of  the  syringe- 
ful,  when  he  noticed  that  he  was  using  the  stronger ;  thus  about 
four  centigrammes  of  the  cocaine  were  injected  into  the  cellu- 
lar tissue  under  the  skin  of  the  lower  eyelid.  This  was  about 
3  P.M.  During  the  operation  there  were  no  disturbances  of  any 
note,  but  upon  rising  from  the  chair  the  patient  exhibited 
marked  titubation.  When  she  was  assisted  into  a  neighboring 
room  syncope  came  on.  Soon  the  respiration  seemed  to  stop, 
the  face  became  cyanosed,  the  lips  blue,  as  though  the  patient 
were  asphyxiated,  but  the  air-passages  were  freely  open.  With 
manipulations  and  injections  of  ether  the  respiration  was  par- 
tially re-established;  but  the  face  remained  congested,  and 
unconsciousness  continued.    At  the  end  of  a  half-hour  some 


52  ARTIFICIAL  ANJESTHESIA. 

words  -nere  uttered,  and  the  patient  was  placed  in  bed.  Caffeine 
was  administered,  but  in  spite  of  all  efforts  death  occurred 
about  8  o'clock  in  the  evening.  No  autopsy. — Recueil  rf'  Oph- 
thalvvdogie. 

The  Injection  of  a  Solution  of  Cocaine  into  the 
Urethra  Followed  by  Death.* — "A.  M.  was  admitted  to 
the  surgical  ward  of  the  Episcopal  Hospital  on  February  23, 
1888.  Age,  twenty-nine  years  ;  English.  He  gave  a  history  of 
having  suffered  from  stricture  of  the  urethra  some  years  before, 
for  which  the  operation  of  external  urethrotomy  had  evidently 
been  performed.  At  the  time  of  admission  there  was  some 
difficulty  in  passing  water,  and  the  urine,  he  said,  'comes  out 
of  an  opening  between  the  legs.'  Upon  examination  there 
was  found  tlie  cicatrix  of  a  perineal  section,  having  a  small 
fistula  communicating  with  the  urethra.  The  urethra  was 
examined,  and  the  existence  of  a  stricture  was  ascertained,  situ- 
ated about  four  and  a  half  inches  from  the  meatus.  The 
stricture  admitted  a  No.  11  French  bougie. 

"  Gradual  dilatation,  by  means  of  sounds  introduced  every 
other  day,  was  the  treatment  under  which  the  patient  was 
placed  for  two  weeks.  Favorable  progress  was  made  and  the 
urethra  now  easily  admitted  a  No.  20  sound.  Internal  urethrot- 
omy was  determined  upon,  in  order  to  remove  all  hindrance 
to  the  passage  of  urine  through  the  urethra,  and  permit  the 
healing  of  the  perineal  fistula.  On  March  3d,  the  day  I  had 
intended  to  perform  the  operation,  the  patient  complained  of 
sore  throat,  had  a  slight  chill,  and  there  was  a  slight  increase 
of  temperature.  This  proved  to  be  nothing  more  than  a  mild 
attack  of  bronchitis.  On  March  9th,  he  was  feeling  quite  well, 
and  I  had  him  removed  to  the  operating-room  for  operation. 

"  Previously  to  performing  internal  urethrotomy,  I  have,  for 
the  past  year  or  two,  injected  into  the  urethra  a  solution  of 
muriate  of  cocaine,  which  has  lessened  the  pain  of  the  opera- 
tion, although  not  completely  rendering  the  parts  insensible  to 
the  cutting.  The  strength  of  the  solution  used  in  my  previous 
cases  had  been  five  per  cent. 

♦By  J.  Henry  C.  Sinies,  M.D.,  surgeon  of  the  Episcopal  Hospital  of  Philadelphia 
Bead  before  the  Philadelphia  Academy  of  Surgery,  June  4,  1888. 


COCAINE.  53 

"The  man  was  placed  upon  the  operating-table,  one  drachm 
of  a  twenty  per  cent,  solution  of  muriate  of  cocaine  was  intro- 
duced into  his  urethra  by  means  of  a  long-nozzled  urethral 
syringe  which  passed  about  four  inches  into  the  canal.  The 
instrument  had  scarcely  been  taken  out  of  the  urethra  when 
the  patient  made  a  foolish  remark,  the  muscles  of  the  face  be- 
gan to  twitch,  the  eyes  staring,  pupils  dilated,  frothing  at  the 
mouth,  face  much  congested,  respiration  interfered  with,  and 
ending  in  a  violent  epileptiform  convulsion,  lasting  for  some 
seconds.  These  convulsions  were  continued  with  increasing 
violence,  several  times  a  minute,  the  whole  muscular  system 
taking  part  in  the  spasms,  requiring  considerable  force  to 
keep  him  from  falling  off  the  table.  The  action  of  the  heart 
was  not  much  interfered  with,  and  only  appeared  to  be  secon- 
darily affected.  It  was  the  respiratory  function  that  seemed 
first  to  fail,  and  then  the  heart's  action  became  irregular  and 
slow.  The  breathing  was  gradually  more  and  more  inter- 
fered with,  the  face — in  fact,  the  entire  surface  of  the  body — 
became  deeply  cyanosed,  the  pulse  slow,  and  at  the  end  of 
twenty  minutes  from  the  first  convulsion,  had  ceased  to  beat. 
The  man  was  dead. 

"The  means  employed  to  relieve  the  patient  were  all  use- 
less; nothing  had  any  effect  in  controlling,  lessening,  or  in 
any  way  influencing  the  ultimate  result,  and  I  may  say  every- 
thing was  promptly  and  efficiently  done ;  the  entire  staff  of 
resident  physicians  of  the  Hospital  ably  assisted  me  in  my 
efforts,  which  unfortunately  were  futile. 

"  The  post-mortem  was  made  by  Dr.  Grimm,  Eesident  Sur- 
geon at  the  Hospital.  Thorax:  Lungs  normal,  but  much 
congested;  heart  normal,  right  side  empty,  left  side  filled 
with  currant-jelly  clots.  Abdomen:  Liver  much  congested; 
spleen  presented  on  its  surface  several  stellate  cicatrices ;  kid- 
neys much  congested  and  also  cicatrices  similar  to  those  seen  on 
the  surface  of  the  spleen;  they  were  thought  possibly  to  be 
syphilitic  in  nature.  The  urethra  was  examined  to  ascertain 
if  there  had  been  a  rupture  made  in  introducing  the  syringe, 
but  no  such  lesion  was  found.  The  brain  showed  the  blood- 
vessels very  much  congested ;    its  membranes  on  either  side 


64  ARTIFICIAL  ANiESTHESIA. 

of  the  longitudinal  sinus  at  the  vertex,  covering  a  space  of 
two  square  inches,  were  thickened  and  closely  attached  to 
the  brain-substance;  this  probably  was  the  result  of  some 
previous  inflammatory  action." 

Zamibianchi  and  Mentalti,  on  Two  Fatal  Cases  of 
Cocaine  Poisoning. — A  lady  suffering  from  recurrent  can- 
cer of  the  breast,  had  three  and  seven-tenths  grains  of  cocaine 
injected  hypodermically  near  the  proposed  site  of  operation. 
Immediately  after  she  was  seized  with  epileptiform  convul- 
sions, which  lasted  fifteen  minutes.  Artificial  respiration 
was  performed,  and  she  rallied  for  a  moment,  but  the  con- 
vulsions came  on  again,  and  in  five  minutes  more  she 
died.  The  second  case  was  that  of  a  woman  suffering 
from  phthisis  of  one  lung,  to  whom  22  grains  of  the  hydro- 
chlorate  were  given  internally  by  mistake.  Fifteen  minutes 
afterwards  she  began  to  wander  in  mind,  complaining  that 
a  morsel  of  food  had  stuck  in  her  throat,  and  making 
fruitless  efforts  to  vomit ;  at  the  same  time  she  became 
so  cold  that  she  had  to  be  wrapped  in  hot  blankets.  The 
delirium  increased,  her  face  was  pale,  the  pupils  dilated, 
the  lips  cyanotic,  and  the  pulse  imperceptible.  Unconscious- 
ness supervened,  and  in  a  short  time  she  died.  On  autopsy 
there  was  found  intense  congestion  of  the  brain  and  spinal 
cord,  as  well  as  of  their  membranes.  The  surface  of  the 
brain  was  covered  with  a  thin  layer  of  sanguinolent  fluid, 
while  the  subarachnoid  space  was  full  of  serum.  Sections  of 
the  brain-substance  in  various  directions  showed  everywhere 
innumerable  minute  bleeding  points,  the  drops  being  conflu- 
ent, so  as  to  give  the  whole  cut  surface  a  reddish  appear- 
ance. There  were  some  recent  hsemorrhagic  infracts  in 
the  healthy  lung ;  the  heart  was  firmly  contracted,  both  ven- 
tricles containing  a  little  blood;  the  spleen,  liver,  stomach 
and  small  intestine  were  excessively  congested ;  the  kidneys 
and  the  bladder  were  normal.  Precisely  similar  conditions 
were  found  in  rabbits  in  which  poisonous  doses  of  hydro- 
chlorate  of  cocaine  were  injected  hypodermically. — Lo  Speri- 
mentale.     Quoted  in  Br.  Med.  Jour.,  Feb.  16, 1889. 

In  a  careful  reading  of   Dr.  Mattison's  before-referred-to 


COCAINE.  55 

monograph,  we  found  a  few  points  on  which  we  wanted  a  lit- 
tle more  definite  information,  and  wrote  to  him  for  that  pur- 
pose, but  received  no  reply  except  from  his  wife,  acknowledg- 
ing the  receipt  of  the  letter  :  The  name  of  the  journal  in  which 
the  details  of  the  Russian  surgeon's  case  is  reported  ?  Might 
not  the  operation  of  scraping  and  cauterizing  a  tuberculous 
ulcer  have  caused  the  death  of  the  young  woman  ?  Wgs  not 
three-quarters  of  an  hour  a  long  time  before  the  cocaine 
had  developed  its  toxic  effects  ?  We  find  as  a  rule  they  are 
decided  in  five  minutes.  We  cannot  find  the  number  of  the 
American  Lancet  in  which  the  case  is  reported  by  Dr.  Long. 
What  was  the  disease  of  the  larynx?  The  case  of  Dr.  F. 
M.  Thomas  was  not  reported  in  any  medical  journal.  We  ap- 
plied to  Dr.  Thomas  by  letter,  addressing  him  Leonardsville, 
Kansas,  for  some  further  information  in  regard  to  his  case,  but 
received  no  reply.  Judging  from  the  symptoms,  the  woman  died 
from  paralysis,  and  had  been  under  treatment  for  the  same.  We 
were  unable  to  find  where  Dr.  Knabe's  case  was  published.  Such 
cases  frequently  die  from  cardiac  degeneration  followed  by  drop- 
sy, the  result  of  scarlatina ;  the  dose  was  so  small,  only  four  to 
twelve  drops — the  exact  amount  not  determined — of  a  four  per 
cent,  solution.  Now  we  come  to  Dr.  Simes'  case.  In  reading 
this  case  over  carefully,  we  are  of  the  opinion,  from  the  symp- 
toms and  the  post-mortem  record,  that  the  man  had  been  an 
epileptic  ;  and  again  a  twenty  per  cent,  solution  is  too  strong, 
and  should  never  be  employed  in  the  urethra  or  rectum,  as  it 
enters  the  veins  by  endosmosis,  and  ifc  also  acts  upon  the  spinal 
nerve  and  has  been  found  a  true  cerebro-spinal  excitant  in 
large  doses.  The  dose  internally  is  one-sixth,  one-fourth,  one- 
third  of  a  grain.  We  find  that  with  a  two  per  cent,  solution  with 
acid  carbolic  gr.  x  to  the  oz.,  we  obtain  all  the  results  we  desire  if 
repeated,  and  if  possible  controlled  by  position,  or  a  ligature  as 
suggested  by  Corning,  of  a  rubber  tube. 

The  case  reported  by  Abadie  is  very  imperfect  in  its  details, 
and  cannot  be  received  until  further  information  is  obtained  ; 
still,  we  consider  it  our  duty  to  publish  all  the  cases  of  alleged 
deaths,  so  as  to  induce  a  proper  caution  in  persons  who  have 
never  employed  the  drug,  just  as  we  would  do  in  prescribing 
morphia  and  other  powerful  alkaloids. 


56  ARTIFICIAL  ANiESTIIESIA. 

In  the  two  cases  reported  by  Zamibianehi  and  Mentalti,  the 
first  was  an  epileptic,  and  the  second  one  afflicted  with  phthisis. 
In  both  cases  the  doses  were  too  large. 

Morbid  Cliaiig:es  in  Acute  and  Chronic  Poisoning-  of 
Dogs  by  Cocaine. 

Dr..VasilyM.  Zautchevsky,  of  St.  Petersburg,  has  published 
an  Inaugural  Dissertation,  1888,  p.  39,  analyzed  by  Dr.  V.  Idel- 
son,  London  Medical  Recorder,  December  20,  1888.  These  ex- 
periments were  conducted  under  the  guidance  of  Prof.  N.  P. 
Ivanovsky,  and  were  made  on  healthy  adult  dogs.  In  one 
group  the  effects  of  lethal  doses,  and  in  another  chronic  pois- 
oning were  studied. 

I.  Acute  poisoning  was  induced  in  five  animals  whose  body's 
weight  varied  from  five  thousand  to  nine  thousand  one  hun- 
dred grammes  (about  ten  pounds)  by  injecting  from  .15  (about 
2  grains)  to  .27  gramme  (or  .03  per  one  kilo)  of  cocaine,  the 
animal  dying  in  from  five  to  sixty  minutes  after  the  injection. 
The  train  of  toxic  symptoms  was  fairly  uniform.  For  a  few 
minutes  after  the  injection  the  dog  either  did  not  present  any- 
thing abnormal,  or  fell  into  a  kind  of  stupor;  then  there  ap- 
peared dilatation  of  pupils,  restlessness,  extreme  dyspnoea  and 
acceleration  of  the  pulse,  and  in  fifteen  minutes  attacks  of 
clonic  spasm,  lasting  for  half  a  minute  or  so,  and  alternating 
with  paroxysms  of  typical  Cheyne-Stokcs  breathing ;  later, 
there  supervened  complete  general  amesthesia,  dilatation  of  the 
palpebral  slit,  congestion  of  the  conjunctiva,  lachrymation,  cya- 
nosis, loss  of  consciousness,  incontinence  of  urine  and  fasces, 
stertorous  breathing,  tremor  of  the  whole  body,  progressive 
failure,  and  retardation  of  cardiac  action. 

II.  Chronic  poisoning  was  brought  about  in  four  dogs 
(weighing  from  five  thousand  six  hundred  to  eight  thousand 
two  hundred  grammes)  by  injecting  cocaine  in  doses  gradually 
ascending  from  three  or  four  (about  .5  per  one  kilo)  to  ten  or 
sixteen  centigrammes  a  day,  the  whole  amount  taken  during 
the  experiment  varying  from  1.08  to  7.8  grammes,  and  death 
ensuing  in  from  forty-three  to  one  hundred  and  seven  days. 
The  initial  small  doses  gave  rise  to  acceleration  of  breathing 


COCAINE.  57 

and  pulse,  fleeting  (fifteen  minutes)  general  restlessness,  also 
consecutive  weakness  of  the  animal's  hind  limbs,  followed  by 
rise  of  the  rectal  temperature  (3°  to  6°  C.)  the  symptoms  disap- 
pearing in  about  three  hours.  Increased  doses  produced  the 
same  and  even  more  pronounced  and  prolonged  symptoms. 
The  7  centigramme  doses  induced  sometimes  manege  move- 
ments of  two  or  three  minutes'  duration,  with  extreme  restless- 
ness, followed  in  four  hours  or  so,  by  extreme  weakness,  and  las- 
situde. The  8  centigramme  doses  gave  rise  to  stupor,  with 
high  dyspnoea,  acceleration  of  the  pulse,  and  mydriasis  of  two 
or  three  hours'  duration.  The  1  decigramme  doses  caused  com- 
plete narcosis,  rise  of  the  rectal  temperature  (1°  C),  decreasing 
sensibility,  and  other  symptoms  of  acute  poisoning.  In  two  of 
the  animals,  there  occurred  several  attacks  of  clonic  spasm. 
Both  of  them  died  suddenly  after  a  convulsive  paroxysm,  with 
consecutive  profound  prostration.  The  other  two  sank  gradu- 
ally from  progressive  extreme  cachexia  (which,  however,  was 
more  or  less  pronounced  also  in  the  two  former  dogs). 

III.  Morbid  lesions,  either  in  acute  or  in  chronic  poisoning 
by  cocaine,  did  not  represent  anything  characteristic  or  path- 
ognomonic. 

A.  Microscopical  Examination. — In  acute  poisoning 
there  were  invariably  found  all  those  alterations  which  occur  in 
cases  of  fatal  asphyxia,  such  as  dark  fluid  blood,  engorgement 
of  the  thoracic  veins,  dilatation  of  the  right  auricle  and  ventri- 
cle of  the  heart,  venous  congestion  and  oedema  of  the  lungs,  ex- 
travasations under  the  pleurae,  pericardium,  endocardium  and 
gastric  mucous  membrane,  cyanotic  liver,  contracted  spleen, 
moderate  hypersemia  of  the  brain  and  spinal  cord,  and  a  more 
intense  one  of  the  meninges.  The  same  changes  also  were 
present  in  these  two  cases  of  chronic  poisoning  which  had  ter- 
minated suddenly,  while  in  the  eminently  cachectic  two  cases 
there  were  detected  extreme  antemia  and  dryness  of  all  the 
organs,  except  the  brain,  medulla  oblongata,  spinal  cord  and 
cerebro-spinal  meninges,  which  were  intensely  congested. 

B.  MiCEOscopicAL  Examination.— Blood  did  not  present 
any  structural  changes. 

Lungs. — In  acute  cases  there  were  present  dilatation  of  the 
3* 


58  ARTIFICIAL   ANAESTHESIA, 

alveolar  vessels,  with  extravasations  and  occasional  collapse  of 
the  alveoli ;  opaque  swelling  of  the  alveolar  epithelium,  hyper- 
semia  and  extravasation  in  bronchioles. 

Liver. — In  acute  poisoning  there  were  found  opaque  swelling 
and  granularity  of  hepatic  cell,  hydropic  and  granular  degen- 
eration of  the  epithelium  of  gall  ducts,  serous  infiltration  of 
the  interlobular  connective  tissue,  engorgement  of  the  interlob- 
ular and  central  veins,  with  occasional  small-sized  extravasa- 
tions in  their  neighborhood,  and  a  distinct  increase  of  glycogen 
in  hepatic  cells.  [The  latter  statement  is  in  accord  with 
Professor  Tarkhau-Mouravoff's  observations,  according  to 
which  large  doses  of  cocaine  rapidly  gave  rise  in  dogs  to  gly- 
couria  of  about  five  hours'  duration  ;  vide  the  liirnal  dla  nomali 
Patolog.,  Heslolog.,  etc.,  Vol.  VI.]  In  chronic  intoxication, 
Dr.  Zautchevsky  found  atrophy  and  albuminoid  degeneration 
of  hepatic  cells,  atrojihy  of  the  interstitial  tissue  and  atrophic 
attenuation  of  vascular  walls.  Heart  presented  considerable 
lesions  in  every  one  of  the  cases.  In  acute  poisoning  there 
were  found  initial  signs  of  albuminoid  degeneration  of  muscu- 
lar fibres,  minute  extravasation  in  the  sub-pericardial  and  a 
lesser  in  the  sub-endocardial  and  interstitial  connective  tissue, 
tumefaction  of  the  eadothelium  of  capillaries,  opaque  swelling 
and  (non-fatty)  granularity  of  many  cardiac  ganglia,  with  indis- 
tinctness of  their  nuclei.  In  cachectic  chronic  cases  the  de- 
generative (albuminoid  and  fatty)  changes  were  still  more 
pronounced,  the  muscular  fibres  having  lost  their  strife,  being 
intensely  granular,  while  the  vessels  were  empty  and  their 
walls  atrophied  ;  the  cardiac  ganglia  presented  extreme  fatty 
degeneration  and  atrophy  of  their  cells,  with  changes  in  the 
protoplasm,  their  nuclei  being  extremely  indistinct.  The 
medulla  oblongata,  especially  the  spinal  cord,  proved  to  have 
undergone  still  more  profound  alterations.  In  acute  cases 
there  was  invariably  albuminoid  degeneration  of  ganglionic 
cells  of  the  medulla  oblongata,  anterior  and  posterior  horns, 
Clarke's  columns  and  Roland's  gelatinous  substance,  and  the 
spinal  changes  being  especially  pronounced  in  the  regions  of 
the  cervical  and  lumbar  enlargements. 

There  were  found,  further,  dilatation  of  perivascular  spaces, 


COCAINE.  59 

small  extravasations  in  the  gray  matter,  and  occasionally  mu- 
coid degeneration  of  the  epithelium  of  the  central  canal.  In 
chronic  poisoning,  side  by  side  with  the  same  (but  more  in- 
tense, and  more  extensive,)  degenerative  lesions,  there  were  de- 
tected hyaline  degeneration  of  nerve-cells  in  the  spinal  gray 
matter,  engorgement  of  veins  and  capillaries,  (especially  in  the 
gray  substance)  and  such  changes  of  vascular  walls  as  prolifer- 
ation of  theirnuclei  and  hyaline  degeneration,  with  consecutive 
varicosity  of  the  diseased  vessels.  All  those  lesions  in  the 
medulla  and  spinal  cord  had  a  circumscribed  character — that 
is,  were  scattered  in  a  patch-like  manner  over  various  districts 
of  the  organs.  Dr.  Zautchevsky  is  inclined  to  think  "  the  de- 
generative changes  arising  in  the  nerve-centres,  under  the  in- 
fluence of  cocaine,  may  be  partly  explained  (apart  from  a  still 
obscure  specific  action  ol  the  alkaloid  on  the  nerve  elements)  by 
a  disturbance  in  the  circulation  of  the  central  nervous  system 
which  is  caused  by  the  drug."  In  acute  poisoning,  cocaine 
brings  about,  in  the  first  instance,  a  rise  of  the  blood-tension, 
with  a  consecutive  diminution  in  the  supply  of  arterial  blood  ; 
a  subsequent  fall  of  the  blood-tension  and  a  synchronic  dis- 
turbance of  breathing,  leading  to  a  profound  alteration  of  the 
blood  in  regard  to  its  gaseous  ingredients  ;  hence  the  altered 
blood  becomes  an  additional  irritant  agent,  and  there  arise 
disturbances  in  the  nutrition  and  degenerative  changes  of  the 
nerve-cells.  It  would  be  superfluous,  of  course,  to  dwell  on  an 
extreme  sensibility  of  the  nerve  tissue  towards  any  slight  devi- 
ation in  the  circulation  or  the  composition  of  blood. 

In  conclusion.  Dr.  Zautchevsky  draws  attention  to  a  close 
similarity  between  the  morbid  lessons  in  the  nerve-centres  as 
found  by  him  in  cases  of  cocaine  poisoning,  and  those  de- 
tected by  Dr.  Cziz  in  cases  of  acute  and  chronic  poisoning 
by  morphia  and  atropia  [Meditz.  Prebaul.  K'Morsk.  Shorn, 
May  and  June,  1883),  the  difference  being  only  a  quantitative 
one  ;  the  former  are  somewhat  milder,  comparatively,  with 
the  latter.  Perhaps  there  exists  a  still  greater  similarity  be- 
tween the  alterations  caused  by  cocaine  and  those  found  in 
the  nerve-centres  and  their  blood-vessels  in  starvation  (as 
described  by  Dr.  V.  Mankovsky,  The  London  Medical  Record, 


GO  AETIFICIAL   ANAESTHESIA. 

Feb.  7,  1886,  p.  73  and  V.  Rosenbach,  in  his  "  St.  Petersburg 
Inaugural  Dissertation,"  1883). 

Judging  from  that  anah)gy,  Dr.  Zautchevsky  arrives  at  the 
general  conclusion  that  "  the  cause  of  those  degenerative 
changes  as  occur  in  chronic  jioisoning  by  cocaine  should  be 
sought  in  disturbed  nutrition  of  cellular  elements,  which  in 
its  turn  depends  upon  lesions  of  vascular  walls,  caused  by 
direct  action  of  the  alkaloid."  ( Therac.  Gazette,  Feb.  15, 
1889.) 


CHAPTER    VI. 

Cocaine  in  Surgery,  also  in  Obstetrics  and  Gynajcclogy. 

Cocaine   Aiiaisthesia   in   Femoral  Supra-condyloitl 
Osteotomy  and.  Excision  of  the  Hip- Joint.* 

Dr.  Roberts  had  obtained  anassthesia  for  one  hour  and 
three-quarters,  over  a  segment  four  inches  broad,  with  three 
grains.  He  had  experimented  upon  a  healthy  person  prior 
to  the  operations  upon  the  patients.  He  had  injected  only  a 
one  per  cent,  solution,  and  had  been  able  afterwards  to  pass 
needles  right  through  the  fleshy  part  of  the  arm. 

The  cocaine  employed,  was  by  Coming's  method,  as  follows  : 
Dr.  Corning,  of  New  York,  first  mapped  out  the  course  of  the 
veins,  rendering  them  prominent  by  a  moderately  tight  rubber 
bandage  on  the  limb,  which  obstructed  the  return  circulation. 
He  then  rendered  the  limb  bloodless  by  means  of  an  Esmarch 
bandage.  The  injection  was  made  very  superficial  at  first,  to 
avoid  pain  from  the  needle,  and  after  partial  antesthetization, 
the  extent  of  the  injection  could  be  enlarged.  Before  sufficient 
time  had  elapsed  for  the  fluid  to  be  carried  away  into  the 
general  circulation,  the  tourniquet  was  applied  at  the  upper 
edge  of  the  antesthetized  zone,  thus  incarcerating  the  liquid  in 
the  field  of  the  operation.  If  the  tourniquet  could  not  be 
employed  on  the  part  operated  upon,  he  made  use  of  hoi'mo- 
static  rings.     By  making  pressure  upon  these,  the  circulation 

*  Dr.  M.  J.  Roberts  reported  cases.  (See  New  Yorli  Medical  Journal,  October  24, 
1885,  p.  459 ) 


COCAINE.  61 

could  be  markedly  decreased  in  the  part  injected.  This  method 
has  now  been  employed  by  a  number  of  physicians  and  sur- 
geons in  this  city,  who  would  testify  to  its  excellent  effects. 
A  one,  a  one-half,  a  one-third,  and  even  a  one-fifth  per  cent, 
solution  of  hydrochlorate  of  cocaine  was  sufficiently  strong  to 
produce  local  anaesthesia  by  this  method.  But  a  one-fifth  per 
cent,  solution  was  not  reliable.  A  one  or  a  half  per  cent, 
solution  was  usually  preferable. 

Cocaine  in  Minor  Surgery  and  Major  Surg^ery. 

If  current  reports  are  to  be  credited,  there  is  apparently  no 
limit  to  the  beneficent  action  of  cocaine.  In  the  London 
Lancet,  Dr.  J.  Herbert  Simpson  reports  the  following  case : 

"Miss  B , whose  breast  I  removed  for  scirrhus  in  February, 

1884,  found  a  week  ago  that  two  small  nodules  of  the  disease, 
each  a.bout  the  size  of  a  pea,  very  hard  and  painful,  had  ap- 
peared near  the  cicatrix  of  the  operation  wound.  The  nodules 
were  about  three  inches  apart.  On  January  23,  I  injected 
three  minims  of  a  four  per  cent,  solution  of  the  hydrochlorate 
of  cocaine  on  either  side  of  one  nodule;  and,  finding  that  after 
waiting  ten  minutes  there  was  no  pain  on  pinching  the  part,  I 
cut  down  and  removed  the  nodule,  having  to  make  an  incision 
an  inch  and  a  half  long.  The  patient  felt  absolutely  nothing 
of  the  operation  until  I  inserted  the  sutures,  and  that,  she  said, 
was  hardly  to  be  called  pain.  After  closing  the  wound,  I 
injected  another  three  minims  near  the  second  nodule,  and 
operated  in  the  same  way ;  and  although  a  little  pain  was  felt, 
owing,  I  believe,  to  my  not  having  waited  suflBciently  long  for 
the  third  injection  to  take  effect,  it  was  very  trifling;  and  from 
beginning  to  end,  this  operation  under  cocaine  was  a  decided 
success.  There  were  no  after-effects  from  the  drug,  and  both 
wounds  are  healing  by  first  intention." 

About  the  last  use  which  we  have  seen  recommended  for 
cocaine  is  its  employment  as  an  anaesthetic  for  the  operation 
of  avulsion  of  ingrowing  toe-nails.  Dr.  F,  Peyre  Porcher 
{Medical  News,  July  11,  1885)  reports  a  case  in  which  the 
instillation  of  a  four  per  cent,  solution  of  hydrochlorate  of 
cocaine,  from   the  point  of  a  hypodermic  needle  upon  the 


62  ARTIFICIAL   ANiESTIIESIA. 

slightly  raw  surfaces  on  each  side  of  the  ingrowing  nail  of  the 
big  toe,  was  perfectly  successful  in  producing  complete  anaes- 
thesia; a  rag  wet  with  the  same  solution  being  kept  pressed 
against  the  upper  surface  of  the  toe,  and  three  injections  of  the 
same  solution  being  made  subcutaneously  at  the  base  of  the 
nail.  Probably  not  more  than  ten  or  fifteen  drops  in  all  were  re- 
ceived and  absorbed.  After  the  lapse  of  fifteen  minutes  the  nar- 
row blade  of  a  fine-pointed  pair  of  scissors  was  passed  under  the 
nail,  which  was  divided  to  the  matrix,  when  the  two  portions 
of  nail  were  forcibly  extracted  without  causing  any  sufiering. 

The  Status  of  Cocaiiie  in  Surgery.* 

After  a  note  or  two  on  the  history  of  cocaine  as  a  surgical 
anaesthetic,  in  which  he  accords  to  Dr.  Karl  KoUer,  now  of 
New  York  city,  but  five  years  ago  of  Vienna,  the  credit  due  for 
its  introduction  for  eye  surgery,  and  to  Dr.  J.  Leonard  Corning, 
of  New  York  City,  the  credit  for  its  practical  application  to 
other  surgical  purposes,  Dr.  Wyeth  proceeds : 

"  For  hypodermic  purposes,  take  twenty  grains  of  cocaine 
and  three  grains  of  boracic  acid  and  dissolve  in  an  ounce  of 
distilled  water — approximately,  a  four  per  cent,  solution.  A 
stronger  aseptic  solution  is  equal  parts  of  distilled  water  and 
saturated  solution  of  salicylic  acid.  Always  dissolve  cocaine 
in  water  free  from  lime. 

"  In  operations  upon  the  extremities,  the  circulation  may  be 
temporarily  arrested.  For  example,  in  amputation  of  the  last 
phalanx  of  the  finger,  first  immerse  the  hand  for  half  an  hour 
in  a  1:2000  solution  of  corrosive  sublimate.  It  is  best  not  to 
Esmarch  the  finger,  but  to  constrict  it  with  a  piece  of  rubber 
tubing.  Direct  injections  (in  the  line  of  incision)  retard  to  a 
slight  degree  union  and  repair  of  wounds.  Hence,  employ  the 
indirect  method  (injection  about  the  nerves  at  the  base  of  the 
finger)  when  possible,  although  this  method  requires  a  little 
longer  time  and  a  little  more  of  the  cocaine  solution.  Just 
before  applying  the  rubber,  insert  the  smallest  size  hypodermic 
needle  through  the  skin  on  the  lateral  aspect  of  the  dorsum  of 

•An  Abstract  of  a  Paper  by  Dr.  John  A.  Wyeth,  of  New  York,  in  Virginia  Medical 
Monlhhj,  October,  1889. 


COCAINE.  ■  63 

the  digit,  about  an  inch  from  and  on  the  distal  side  of  the 
ligature.  Inject  about  two  minims ;  push  the  needle  a  quarter 
inch  farther,  and  inject  two  minims  more,  etc.,  until  the 
needle-point  rests  just  beneath  the  skin,  on  the  plantar  aspect 
of  the  finger,  when  the  same  quantity  is  injected.  Thus  one- 
half  of  the  finger  is  injected,  and  the  operation  is  immediately 
repeated  on  the  other  half — the  entire  operation  not  occupying 
more  than  30  seconds.  A  smarting,  burning  pain  is  felt  as  the 
fluid  enters.  Tighten  the  tourniquet  at  once,  thus  holding  the 
solution  at  a  standstill  for  absorption,  which  may  be  hastened 
by  massage  over  the  injected  area.  Insensibility  supervenes  in 
about  two  minutes.  Usually  about  15  minims  are  suflScient, 
but  30  minims  may  be  thus  used  safely. 

"  The  operation  being  finished,  loosen  the  band  for  only  a 
minute,  which  restores  the  circulation,  and  (under  sublimate 
solution)  the  wounds  bleed  freely,  thus  giving  escape  to  what- 
ever of  the  solution  the  arterioles  may  have  absorbed ;  but  of 
course  a  certain  amount  is  carried  into  the  general  circulation. 
Tighten  the  rubber  again  for  about  two  or  three  minutes,  and 
insert  sutures  and  apply  the  dressing.  Gradually  accustom 
the  general  circulation  to  the  cocaine  by  alternately  loosening 
and  tightening  the  tourniquet.  The  heart  and  nerve  centres 
might  be  overwhelmed  if  the  entire  excess  is  suddenly  let 
loose  into  the  general  circulation. 

"The  advantages  of  the  direct  method  are:  Rapidity  of 
anaesthesia;  the  small  quantity  of  cocaine  used;  escape  of 
much  of  the  solution  through  the  wound  of  incision.  This 
method  is  preferable  for  incising  felons,  removing  diseased 
nails,  foreign  bodies,  etc.  Indeed,  any  procedure  where  the 
necessary  anaesthesia  can  be  obtained  by  not  more  than  a 
drachm  of  a  four  per  cent,  solution  may  be  safely  done  with 
this  agent  by  the  direct  method. 

"  In  operations  upon  the  trunk,  the  immediate  absorption  of 
the  solution  renders  greater  precaution  necessary.  For  in- 
stance, if  a  fatty  tumor  is  to  be  removed,  insert  the  needle  into 
the  deepest  layers  of  the  skin  (not  subcutaneous  fat)  along  the 
line  of  proposed  incision,  and  inject  half-minim  or  minim ; 
advance  the  needle  a  quarter  of  an  inch,  and  repeat  the  injec- 


64  ARTIFICIAL   ANESTHESIA. 

tion,  and  so  on  as  far  as  the  needle  will  reach  from  the  original 
puncture.  Repeat  the  injections,  if  necessary,  for  a  length  of 
three  inches  until  anaesthesia  is  established.  The  anaesthesia  is 
evident  by  the  pallor  of  the  overlying  cuticle.  Divide  the  skin 
through  the  middle  of  the  ana?sthetized  line,  and  continue  the 
dissection  laterally  until  pain  is  experienced.  Insensibility  often 
spreads  an  inch  or  more  on  either  side  of  this  line.  Inject  a  half 
minim  or  more  at  all  sensitive  points  in  the  line  of  incision. 

"Since  scars  are  to  be  avoided,  cocaine  is  not  so  free  from 
objections  on  the  face  and  neck  as  elsewhere.  In  eye  surgery, 
the  uses  of  this  agent  are  too  well  known  to  require  remark. 
In  the  buccal  cavity,  it  has  a  wider  range  of  application. 
Tumors  of  a  half  inch  to  not  more  than  an  inch  can  be  pain- 
lessly excised.  Small  epitheliomata  or  suspicious  ulcers  are 
painlessly  removed  from  tongue,  when  5  to  20  minims  of  a 
4  per  cent,  solution  are  injected  beneath  and  around  their 
bases.  He  has  twice  dissected  out  ranuhe  successfully.  Com- 
plete cleft  of  the  soft  palate  in  the  adult  can  be  painlessly  closed 
by  applying  the  solutio  n  to  the  mucous  surface  with  a  brush. 
Cocaine  is  in  every  day  use  for  the  larynx,  nose  and  nasopharynx. 

"  For  internal  urethrotomy,  regardless  of  location,  he  rarely 
employs  general  anaesthesia  now.  Disinfect  (he  urethra  with 
boracic  acid  solution  (gr.  x  to  5J);  inject  ,^j — ij  of  a  4  percent, 
solution  of  cocaine  with  the  ordinary  P  syringe.  At  the  end 
of  a  minute  or  so,  let  all  of  the  cocaine  solution  that  will  run 
out  of  the  urethra  run  out.  If  the  operation  is  to  be  in  the 
membranous  portion,  pass  the  long  curved  tube  of  Otis  into  the 
part,  and  inject  from  20  to  30  minims.  For  the  introduction  of 
the  sound  on  the  third  day  after  urethrotomy,  be  careful  not  to 
over-distend  the  canal  with  the  preliminary  cocaine  injection  ; 
about  a  drachm  of  the  solution  is  then  as  much  as  should  be 
used.     For  bladder  examinations,  cocaine  is  very  useful. 

"Circumcision  in  adults  no  longer  requires  general  narcosis. 
Constrict  the  penis  near  the  pubes,  pull  forward  the  prepuce, 
and  enter  the  hypodermic  needle  at  the  free  border  in  the 
middle  line  on  top,  between  the  mucous  and  cutaneous  layers. 
Then  carry  the  point  of  the  needle  back  as  far  as  the  proposed 
line  of  section,   and  force  out  one  minim  of  the  4  per  cent. 


COCAINE,  65 

solution.  Withdraw  the  needle  half  way,  carry  forward  again 
to  the  right  and  left,  and  force  out  a  minim  for  every  quarter  ot 
an  inch  of  the  line  of  section.  On  account  of  the  sensitiveness 
about  the  frenum,  it  is  best  to  inject  two  or  three  minims  here. 
"In  Levis'  operation  for  hydrocele,  cocainize  the  point  where 
the  trochar  is  to  enter.  If  the  hydrocele  is  small,  Volkman's 
operation  may  also  be  done  with  cocaine  anassthesia.  In  the 
open  operation  for  varicocele,  cocaine  is  not  sufficient;  nor  is 
it  sufficient  for  external  urethrotomy,  cystotomy,  hernia,  etc. 
But  small  hemorrhoids  may  be  injected  or  cut  away  after 
cocaine  injections.  Cocaine  is  sufficient,  also,  for  fissures  and 
ulcers  of  the  anus  and  rectum.  It  is,  also,  sufficient  for  a 
single  and  superficial  anal  and  rectal  fistulse." 

Cocaine   in  Hemorrhoids,   Fissures,  Fistulas,  and 
Diseases  of  tlie  Anus. 

The  use  of  cocaine  in  diseases  of  the  anus,  hemorrhoids, 
fissures,  and  fistulas,  has  not  always  been  a  success,  as  proven 
by  the  use  of  the  drug  by  Dr.  James  Collins,  surgeon  to  the 
German  Hospital  in  this  city,  in  operating  for  bleeding  piles  ; 
and  Dr.  P.  D.  Keyser,  in  a  case  of  fissure  of  the  anus.  The 
first  found  it  had  no  ansesthetic  properties  in  relieving  the 
pain  of  the  operation,  and  the  latter,  that  the  pain  and  burn- 
ing sensation  were  increased  by  its  use  in  his  case  of  fissure. 
Yet,  on  the  other  hand,  surgeons  have  reported  its  successful 
use  in  this  country,  and  abroad,  the  most  recent  being  with 
Dr.  Bettelheim,  of  Vienna,  who  reports  the  case  of  a  patient, 
aged  seventy-four,  who  had  a  well-marked  anginal  attack 
(London  Lancet,  January  17,  1885),  who  also  had  rectal  and 
vesical  tenesmus,  with  enlarged  prostate.  Cocoa-butter  sup- 
positories were  ordered,  each  containing  half  a  grain  of  muriate 
of  cocaine.  One  of  these  was  introduced  into  the  rectum  at 
bed-time,  and  the  patient  slept  well,  and  was  not  troubled 
during  the  night.  The  beneficial  eifects  were  apparent  the 
whole  of  the  following  day.  The  suppository  was  not  given 
that  evening  and  the  patient  passed  an  uncomfortable  night, 
being  very  restless.  The  next  day  another  suppository  was 
ordered,  and  acted  as  well  as  the  first. 


6Q  ARTIFICIAL   ANiESTHESIA! 

In  the  operation  for  hemorrhoids  by  Dr.  Joseph  M.  Mathews, 
of  Louisville,  Kentucky,*  it  is  stated  us  his  experience,  after 
one  thousand  operations  "in  the  removal  of  external  piles, 
much  benefit  is  derived  from  cocaine,  strength  not  given,  from 
throwing  the  solution  under  the  growth."  In  the  operation  for 
internal  piles  he  has  found  it  of  little  value. 

A  more  recent  communication  on  the  subject: 

Kentucky  School  of  Mbdicine, 
Louisville,  Ky.,  Dec.  25,  1888. 
Dr.  Laurence  Tcrnbull,  Philadelphia. 

Dear  Doctor : — Your  favor  received.  In  answer  to  the  question 
"what  anesthetic  I  prefer  in  operating  for  hemorrhoids?"  would 
say  that  it  is  invariably  my  custom  to  use  chloroform.  I  have  used 
it  in  many  hundred  cases  and  never  had  a  death.  It  is  always  my 
custom  to  precede  its  use  by  a  good  drink  of  whiskey.  I  employ 
very  seldom  cocaine  in  operations  around  the  rectum  and  anus,  for 
the  reason  that  I  regard  it  as  both  dangerous  and  of  little  service. 
Where  a  superfluous  amount  of  skin  h:vs  to  be  removed  from  around 
the  anus,  I  sometimes  inject  from  ten  to  twenty  drops  of  a  four  per 
cent,  solution  into  and  under  the  same.  In  operating  for  internal 
hemorrhoids  I  never  employ  it. 

Cocaine  in  Operations  on  the  Bladder  and  Urethra. 

We  would  call  attention  to  the  value  of  cocaine  in  oi^era- 
tions  upon  the  bladder  and  urethra,  in  preventing  damage  to 
an  unhealthy  kidney,  also  in  the  differential  diagnosis  of  uri- 
nary disease.  If  a  real  pain  is  relieved  by  cocaine,  the  neuralgia 
is  probably  due  to  a  slight  irritation  such  as  that  experienced 
in  lithiasis  congestion  or  grit.  The  editor  of  the  Lancet  states, 
that  cocaine  is  now  being  largely  used  in  these  affections,  in 
ointments  and  suppositories,  in  many  of  the  London  Hospitals, 

Cocaine  being  insoluble  in  oily  and  fatty  substances,  it  is 
advisable,  in  cases  where  it  has  to  form  an  ingredient  of  a 
pomade  or  suppositories,  to  first  dissolve  it  in  oleic  acid  by 
small  quantities  at  the  time.  Treated  in  this  manner,  the 
cocaine  will  assimilate  itself  with  the  greasy  substance  and  a 
homogeneous  preparation  will  be  obtained. 

*  Trans.  Am.  Med.  Assn. 


COCAINE.  67 


Circumcision  Under  Cocaine  Anaesthesia.* 

"In  the  imagination,  a  few  operations  like  the  following  may 
have  occurred,  but  as  far  as  recorded  instances  of  the  kind  are 
concerned,  we  believe  there  are  none.  In  the  first  place  a  sub- 
ject is  required  possessing  age,  liberal  scientific  views,  sound 
mind  and  excellent  health.  The  subject  of  this  sketch  is  a 
gentleman  possessing  all  these  requisites,  with  the  chief  requi- 
site necessitating  the  operation  for  phimosis.  His  recent  life 
has  shown  remarkable  strength  of  mind  and  body.  Naturally 
iovial,  and  quite  delighted  to  impart  the  knowledge  he  pos- 
sesses regarding  the  earlier  history  of  this  city,  he  can  dilate 
upon  its  growth,  commercially,  financially  and  politically. 

''He  has  suffered  severely  at  times  during  micturition, — from 
the  prepuce  adhering  to  and  about  the  meatus  urinarius  ;  the 
penis  was  usually,  with  the  preputial  folds  included,  drawn 
down  at  least  one-third  and  frequently  one-half  an  inch  below 
the  abdominal  surface  of  the  surrounding  pubes ;  the  pain  was 
necessarily  mischievous,  from  irritation,  during  micturition  ; 
the  preputial  adherent  folds  about  the  meatus  caused  a  divided 
and  frequently  a  spraylike  stream,  which  now  and  then — say 
every  six  or  eight  weeks — would  cause  a  '  spell '  that  fre- 
quently lasted  several  days;  recently  one  of  these  'spells' 
became  so  troublesome  that  medical  aid  was  summoned,  and 
it  was  decided  to  perform  circumcision.  The  gentleman's 
age  being  considered,  and  feeling  that  three  heads  are  better 
than  one,  Dr.  William  Stevens  called  Dr.  William  M.  McLaury 
as  counsel  in  the  case,  and  invited  Dr.  M.  Josiah  Koberts  to 
perform  the  operation,  which  was  beautifully  done,  and  the 
patient  is  at  present — two  months  after  the  operation — in  fine 
condition,  with  a  splendid  chance  of  a  much  longer  life,  with- 
out further  inconvenience  from  the  penis  that  should  have 
been  treated  in  like  manner  just  ninety  years  and  ten  days 
before. 

"  Only  a  local  anaesthetic  was  used  in  this  operation.  A  two 
per  centum  solution  of  hydrochlorate  of  cocaine    was  hypo- 

*  New  York  Monthly,  Kov.,  1886,  p.  107. 


G8  ARTIFICIAL  ANAESTHESIA. 

dermically  injected  into  the  preputial  folds,  anterior  to  the 
rubber-cord  bandaging  at  the  base  of  the  penis;  the  local 
anaesthesia  being  so  perfect  that  telling  anecdotes  was  the 
manner  the  patient  passed  the  entire  time  until  the  operation 
was  completed;  no  untoward  symptoms  occurred,  and  perfect 
healing  of  the  parts  by  first  intention,  with  complete  recovery, 
followed  within  a  few  days." 

Cocaine  in  Obstetrics  and  Gynaecolog-y. 

Analgesia  of  the  Genital  Passages  Obtained  by 
THE  Local  Application  of  Cocaine  during  Labor.— 
Dr.  Doleris,  having  a  case  of  placental  polypus  (?)  occurring 
in  consequence  of  abortion,  and  having  to  deal  with  an  uncon- 
trollable vaginal  spasm,  making  examination  very  difficult, 
succeeded  in  completely  suppressing  the  pain  and  irritability 
by  the  application  of  cocaine,  used  a  quarter  of  an  hour  before 
the  operation.  (He  used  hydrochlorate  of  cocaine  in  solution 
of  5  :  100.)  This  encouraged  him  to  undertake,  with  Mr. 
Dubois,  a  series  of  analogous  experiments  upon  women  in 
labor.  They  used  a  solution  of  hydrochlorate  of  cocaine  4  per 
cent.  :  100,  mixed  with  lard  in  eight  cases.  In  six  of  these 
cases  the  result  was  very  marked.  With  a  case  of  a  primipara, 
in  which  dilatation  of  the  cervix  caused  severe  pain,  after  one 
or  two  minutes  following  the  painting  of  the  cervix  with  co- 
caine, perfect  relief  was  afforded.  With  the  others,  during  the 
period  of  expulsion,  the  pain  was  only  in  the  uterus,  and 
allowed  them  to.  assist  freely  by  muscular  contractions.  With 
two  of  the  cases  there  was  no  effect  produced,  showing  that 
there  are  unknown  factors  which  retard  or  prevent  the  action 
of  cocaine.  These  cases  received  before  and  at  the  beginning 
of  labor,  injections  of  corrosive  sublimate — 1  to  2000  solution. 
The  genital  mucous  membrane  became  thoroughly  saturated 
with  this  solution,  a  part  necessarily  remaining  in  the  vagina. 
The  sublimate  decomposes  the  alkaloids  very  rapidly,  and 
there  is  no  doubt  but  this  fact  exerted  a  strong  influence  in 
these  two  cases.  The  amount  of  the  preparation  of  cocaine 
necessary  for  the  purpose  was  from  50  to  60  drops  of  the  4  :  100 
solution,  or  3  to  4  grammes  of  the  ointment,  which  was  abso- 


COCAINE.  69 

lutely  free  from  danger.  The  regular  progress  of  tlie  labor 
was  not  retarded,  and  it  was  only  the  general  sensibility  that 
was  blunted;  the  reflex  sensibility  remained  normal.  The 
uterine  contractions  continued  with  their  usual  intensity, 
duration  and  frequency.  These  observations  were  commu- 
nicated by  Dr.  Doleris  to  the  Societe  de  Biologie  (Seance  du 
17  Janvier,  1885).  Since  then  he  has  added  seven  cases  to  his 
list  and  concludes : 

1.  That  cocaine  exerts  no  influence  on  the  pains  of  uterine 
contractions,  but  they  do  not  become  excessive. 

2.  That  but  little  pain  exists  after  analgesia,  the  cocaine 
affording  relief  to  that  pain  which  occurs  in  consequence  of 
distension  and  irritation  of  the  nerves  of  the  supravaginal  and 
intra  vaginal  portions  of  the  neck  of  the  uterus  and  of  the 
vagina  itself. 

3.  That  no  relief  is  afforded  against  the  severe  pain  which  is 
due  to  compression  of  the  nerve  trunks  of  the  pelvis. 

4.  That  the  pain  felt  in  the  mucous  membrane  and  in  the 
vulva  on  expulsion  is  perfectly  relieved.  Expulsion  is  pain- 
less and  very  rapid,  lasting  from  ten  to  fifteen  or  twenty-five 
minutes.  Dr.  Doleris  intends  to  continue  his  observations  by 
studying  the  influence,  as  an  analgesic,  of  bromide  of  potas- 
sium alone  or  combined  with  cocaine.  {Archives  de  Tocolo- 
gie,  etc.,  Feb.,  1885.  Journal  Am.  Med.  Assocn.,  April  11, 
1885.) 

Cocaine  in  Dysmenorrhoea. 

In  the  Medical  News,  Dr.  John  Forrest  relates  the  case  of  a 
patient  who  had  suffered  for  years  from  painful  menstruation, 
accompanying  a  retroflexion  of  the  uterus,  complicated  with 
adhesions.  The  deformity  of  the  uterus  had  been  rectified  by 
treatment,  but  the  pain  during  the  menstrual  period  was  still 
as  agonizing  as  ever.  The  most  acute  and  intolerable  anguish 
was  felt  in  the  left  inguinal  region,  and  was  accompanied  by^ 
wind  colic  that  caused  the  sufferer  to  writhe  in  agony.  Nau- 
sea and  vomiting  added  to  her  distress,  and  she  seemed  at 
times  ready  to  go  out  of  her  mind  with  suffering. 

While  attempting  to  effect  a  permanent  cure  of  this  condi- 
tion by  appropriate  treatment,  temporary  relief  by  the  admin- 


70  ARTIFICIAL  ANiESTHESIA. 

istration  of  morphine  was  all  that  could  be  afforded ;  at  the 
same  time,  that  drug  produced  such  disagreeable  effects,  that 
the  remedy  was  only  not  quite  so  bad  as  the  disease.  But  on 
one  occasion,  instead  of  morphine.  Dr.  Forrest  used  cocaine, 
injecting  subcutaueously  over  the  left  ovary  at  first  three,  in- 
creased afterwards  to  five,  mimims  of  a  four  per  cent,  solution. 
Almost  immediately  after  each  injection  the  pain  in  the  in- 
guinal region  ceased  to  be  felt,  the  nausea  and  wind  colic  were 
relieved,  and,  instead  of  nervous  excitement  and  wakefulness, 
a  soothing  effect  inclining  to  sleep  was  experienced.  Five 
mimims  of  a  four  per  cent,  solution  were  sufficient  to  afford 
complete  relief  for  five  or  six  hours,  and  comparative  immu- 
nity for  a  much  longer  period. 

While,  however,  the  drug  acted  thus  admirably,  both  locally 
and  generally,  it  had  no  effect,  apparently,  on  the  bearing- 
down  pains  and  pain  in  the  back,  but  only  upon  the  local 
pain  in  the  neighborhood  of  the  spot  where  it  was  injected. 
It  was  also  noticed  that,  while  it  relieved  the  nausea  and 
vomiting  of  reflex  origin,  it  sometimes  caused  slight  nausea 
itself,  but  this  was  only  temporary.  No  other  unpleasant 
effect  was  experienced,  if  we  except  a  slightly  bitter  taste  im- 
parted to  the  tongue. 

If  cocaine  can  thus  be  made  to  supersede  morphine  in  such 
cases,  it  will  certainly  prove  an  inestimable  boon  to  many  an 
unfortunate  sufferer.  And  if  it  is  able  to  relieve  that  excru- 
ciating intestinal  pain  usually  called  wind-colic,  which  in  so 
many  cases  is  sure  to  follow  the  slightest  surgical  interference 
with  the  uterus,  this  of  itself  will  be  no  mean  trophy  added  to 
its  many  wonderful  triumphs  over  human  suffering. 

Cocaine  in  Vaginismus. 

In  the  Medical  Press,  we  read  that  Dr.  G.  De  G.  Griffith  has 
found  this  new  and  greatly-vaunted  remedy  useful,  in  the  above 
condition.  Speaking  of  a  case  of  vaginismus  and  dyspartemia, 
he  says : 

"The  patient  came  to  me  suffering  very  acutely;  not  only 
was  pressure  on  the  perineum  exquisitely  painful,  but  the  bare 


COCAINE.  71 

touching  it  was  pain ;  indeed,  blowing  on  it  produced  distress, 
and  so  intolerable  was  the  suffering  that  examination  had  to 
be  completed  under  chloroform.  On  the  third  occasion  of 
attending  the  patient,  I  mopped  the  perineum,  fourchette  and 
lower  part  of  the  vagina  with  a  solution  of  the  cocaine,  after 
which  I  was  able  to  introduce  the  large-sized  Fergusson's 
speculum,  which  was  retained  for  about  two  hours,  as  steady, 
continuous  pressure  had  been  found  to  give  relief.  I  wish 
particularly  to  draw  attention  to  the  ease  procured  by  the 
cocaine,  although  it  was  transient." 

Mr.  John  Phillips  publishes  in  the  London  Lancet,  Nov.  26, 
1887,  Jur.  Oazatten,  Jan.  7,  1887,  an  analysis  of  the  more  im- 
portant contributions  to  the  subject  of  cocaine  in  obstetrics, 
with  the  practical  conclusions  which  we  give  in  brief:  1.  That 
cocaine  in  whatever  way  administered,  for  uncontrollable 
vomiting  in  pregnancy,  is  a  superior  drug  to  those  at  present 
in  vogue.  2.  That  during  the  earlier  painful  stages  of  labor, 
especially  in  primipara,  it  materially  assuages  the  pains,  but 
neither  quickens  nor  retards  their  onset,  and  hence  has  no 
effect  on  the  actual  dilatation.  3.  That  it  is  useless  in  miti- 
gating the  pains  of  expulsion  and  those  caused  by  pressure  on 
the  perineum.  4.  That  in  the  case  of  sore  nipples  it  relieves 
the  pain  attendant  on  suckling,  though  the  duration  of  its 
effects  is  not  suflaciently  long  to  be  of  material  service.  It  is, 
however,  without  any  apparent  detrimental  effect  upon  the 
suckling. 

The  French  and  Italians  allege,  and  with  good  cause,  that 
they  have  met  with  brilliant  success  in  the  employment  of 
cocaine  for  the  alleviation  of  pain,  in  diseases  of,  or  operations 
on,  the  uterus,  pelvic  or  external  organs  in  the  following  cases : 
Vaginismus,  ulceration  of  the  cervix,  advanced  cancer,  allevi- 
ating the  pain  caused  by  caustic  in  sub-cutaneous  injection  in 
such  cases.  Simultaneous  injections  of  cocaine  and  morphia 
produced  even  better  results. 


72  ARTIFICIAL  ANAESTHESIA. 

Means  to  Prevent  the  Injurious  Eflfects  from  Co- 
eaiue  l>y  Local  AnoL'Stliesia   in  Dentistry 
and  Minor  Surg-ery.* 

Dr.  Aubeau,  of  Paris,  employs  in  his  experiments  a  solution 
of  cocaine,  5^/p,  that  is  to  say,  that  in  every  Pravaz  syringe 
containing  a  gramme  of  distilled  water,  he  dissolves  only  5 
centigrammes  of  cocaine,  an  insufiicient  quantity  for  cases 
where  the  roots  of  the  teeth  are  firmly  set  in  the  alveolar  pro- 
cess. 

Mr.  Telschow  injects  10  centigrammes  of  cocaine,  evidently 
too  powerful  a  dose,  as  it  produces  general  trouble  in  a  num- 
ber of  cases. 

Prof.  Viau  combines  another  local  anoesthetic  with  a  small 
quantity  of  cocaine,  5  centigrammes,  which  unites  in  acting 
with  the  cocaine  without  affecting  the  general  health.  This 
second  substance  is  pure  crystallized  phenic  or  carbolic  acid. 
This  acid  neutralizes  the  effect  of  the  solution  of  cocaine,  and 
has  been  used  with  success.  Mr.  Telschow  weakens  his  solu- 
tion of  cocaine  with  the  phenic  acid  to  neutralize  it.  The 
author  finds  an  important  agent  in  the  acid,  the  anassthetie 
properties  of  the  pure  or  concentrated  acid  being  known  to 
all  who  have  used  it.  It  is  the  ana?sthetic,  par  excellence,  of 
intelligent  dentistry.  The  author  now  describes  his  two 
modes  of  administering  anaesthetics  : 

"  1.  Anaesthesia  by  the  aid  of  sub-mucous  injections  with  a 
mixture  of  cocaine  and  phenic  acid. 

"  2.  Anaesthesia  ^by  the  aid  of  sub-mucous  injections  with  a 
^solution  simply  of  phenic  acid. 

"  Local  anesthesia  obtained  by  the  aid  of  cocaine 
AND  phenic  acid  MIXED. — Before  beginning  to  describe  this 
process,  I  should  relate  an  experiment  that  I  made  for  the 
purpose  of  investigating  the  properties  of  a  solution  of  pure 
cocaine  (alkaloid)  in  the  pure  crystallized  phenic  acid.  In 
mixing  one  part  of  phenic  acid  and  two  parts  of  cocaine, 

*  Extract  from  a  monograph  by  Prof.  George  Viau,  officer  of  the  Academy,  Pro- 
fessor of  the  Dental  School  and  Hosi^ital,  Paris ;  Secretary  General  Association  of 
Dentists  in  France  ;  Member  of  the  Council  for  the  Direction  of  the  Dental  School. 


COCAINE.  73 

heating  it  very  slightly,  a  product  of  a  syrupy  quality  is  ob- 
tained, which  retains  the  color  of  the  pure  phenic  acid,  but 
dissolved  ;  that  is  to  say,  rosy ;  and  the  odor  weakened  by 
the  acid.  The  taste  on  the  contrary  is  decidedly  modified. 
The  pheaic  acid  has  lost  its  causticity,  and  its  peculiar  taste. 
In  using  this  product  upon  the  gums  or  tongue,  a  sensation 
of  warmth  is  perceived  with  the  taste  of  the  weakened  phenic 
acid,  allowing  the  bitterness  of  the  cocaine  to  penetrate.  At 
the  end  of  several  seconds  the  taste  and.  the  odor  of  the 
phenic  acid  disappear  completely,  at  the  same  time  that  the 
sensation  of  heat  is  perceived  at  the  moment  of  contact ;  the 
taste  of  the  cocaine  alone  remains,  with  complete  insensibility 
to  pain, 

"Have  I  obtained  in  this  manner  a  phenate  of  cocaine,  or 
have  I  produced  a  simple  solution  ?  I  leave  to  those  more 
competent  the  solution  of  this  question. 

"  However  it  may  be,  I  have  a  product  which  fully  answers 
my  requirements.  Below  is  a  succinct  description  of  my  op- 
erative procedure,  thus : 

"  1.  The  filtered  solution  : 

Crystallized  phenic  acid 2  gr. 

Distilled  water 100  gr. 

"2.  Packages  of  hydrochlorate  of  cocaine.  A  syringe  of 
Pravaz,  containing  a  gramme  of  water,  in  which  I  made 
a  slight  modification  by  adding  to  the  opposite  side  of  the 
canula  a  shoulder-piece,  enabling  me  to  hold  it  with  greater 
ease  and  strength,  with  the  index  and  middle  finger,  whilst 
I  press  the  stem  of  the  piston  with  the  thumb.  I  have 
also  invented  sharp  canulas  of  different  lengths,  which  are  ab- 
solutely necessary,  in  difficult  cases  of  contraction  of  the  jaws, 
to  reach  the  wisdom  teeth.  I  dissolve,  when  required,  5  cen- 
tigrammes (or  1  grain)  of  cocaine  in  50  centigrammes  (10 
drops)  of  phenic  solution,  and  inject  slowly  half  of  the  mix- 
ture into  the  'labial  face,'  half  into  the  lingual  or  palatine — 
at  a  point  situated  between  the  neck  of  the  tooth  and  the  pre- 
sumed place  of  the  extremity  of  the  root,  to  within  2  or  3 
millimetres  of  that  extremity.  I  am  careful  to  hold  a  finger, 
4 


74  ARTIFICIAL   ANAESTHESIA. 

of  the  left  hand,  upon  the  puncture,  to  prevent  the  liquid 
from  liowing  backwards.  The  patient  must  then  wash  out  the 
mouth  with  fresh  water.  At  the  end  of  three  minutes  the 
soft  parts  are  completely  insensible.  A  very  deep  puncture  ia 
no  longer  felt.  Between  the  iifth  and  sixth  minute  I  operate. 
This  process  has  always  given  me  complete  results,  as  regards 
anaesthesia.  As  to  general  troubles  I  have  never  tried  them. 
Sex  and  age  appear  to  have  no  influence  on  the  anajsthetic  re- 
sults. I  have  operated  upon  30  males  and  56  females — total, 
86  subjects.  It  will  be  seen  in  the  table*  of  observations  that 
several  subjects  have  received  the  antesthetic  twice  at  the  same 
sitting,  without  having  been  otherwise  affected.  These  pa- 
tients have,  however,  absorbed,  in  a  lapse  of  some  minutes,  10 
centigrammes  of  cocaine  in  a  gramme  of  phenic  solution. 
Other  patients  have  undergone,  with  several  hours'  interval, 
two  or  three  operations,  always  with  success.  I  have  also  ob- 
served that  the  patients  upon  whom  I  operate  for  the  second 
or  third  time  have  lost  all  fear.  Jn  submitting  thus  to  the  op- 
eration, it  is  evident  that  this  facilitates  many  anaesthetic  in- 
jections— a  work  requiring  great  precision.  Observations 
show  that  the  half  of  the  ordinary  dose  of  anaesthetic — that  is  to 
say,  about  2  centigrammes,  i  gr.  of  cocaine  in  25  centigrammes 
of  phenic  solution — has  sufficed  to  produce  anaesthesia." 

In  conclujiion,  he  thinks  he  will  be  able  to  diminish  here- 
after the  quantity  of  cocaine,  and  to  inject  less  liquid  under 
the  gums;  altogether,  obtaining  a  complete  local  anaesthesia 
for  the  extraction  of  teeth. 

We  were  highly  delighted  to  find,  from  the  pamphlet  of 
Prof.  Viau,  that  he  had  been  able  to  modify  the  hydrochlorate 
of  cocaine  in  solution  with  pure  phenol,  so  as  to  prevent,  in  87 
cases,  any  unpleasant  results  from  its  use  in  the  extraction  of 
teeth.  The  solution  was  prepared  as  directed  by  the  Paris 
Dental  Surgeon,  and  before  a  class  of  about  200  students, 
the  mixture  was  injected  into  the  jaw,  in  a  case  of  diseased 
antrum  in  a  young  lady.  She  was  then  operated  upon  by 
Dr.  Garretson,  who  removed  the  diseased  bone  with  the  den- 
tal engine.     She  bore  the  operation  w'ith  great  equanimity,  and 

*Xot  given  on  account  of  tlie  want  of  space. 


COCAINE.  75 

with  so  little  pain  as  to  be  unnoticed  by  the  students ;  and 
when  asked  at  the  completion  of  the  operation,  she  stated 
that  she  experienced  some  slight  pain.  The  case  was  an  in- 
teresting one,  in  its  freedom  from  excitement  and  haste,  and 
the  quiet  way  in  which  she  would  rise,  expectorate  the  blood, 
and  be  cleansed  from  the  horrible  disfigurement,  avoiding  the 
great  risk  produced  by  profound  ani3esthesia,  which  is  so  nigh 
unto  death,  required  in  such  an  important  operation. 

A  little  girl  was  also  operated  upon,  for  the  extraction  of 
teeth ;  she  cried  when  the  hypodermic  syringe  pricked  her, 
yet  in  seven  minutes  the  very  much  decayed  tooth  was  ex- 
tracted without  the  slightest  evidence  of  pain.  We  think 
this  combination  has  a  wonderful  future,  and  we  have  used  it 
continuously  in  office  work  and  in  operations  with  succe:S. 

Cocaine  in  Intra-nasal  Siu*g-ery. 

(1)  We  have  found  cocaine  is  useful  in  intra-nasal  surgery, 
as  a  local  anaesthetic,  for  the  removal  of  deep  as  well  as  super- 
ficial tissue  abnormalities. 

(2)  Eepeated  applications  are  required  for  the  removal  of 
the  deeper  structures,  the  time  requisite  for  anaesthesia  always 
being  shorter  after  the  first  effect  has  been  obtained, 

(3)  By  promoting  quiet  and  preventing  secretion,  hemor- 
rhage and  sneezing,  it  facilitates  the  employment  of  cutting 
instruments  within  the  nasal  cavity. 

(4)  The  action  of  cocaine  for  profound  anaesthesia  depends 
upon  the  quality  and  the  quantity  of  the  salt. 


CHAPTER  VII. 

Therapeutics  of  Cocaine — Gastritis  produced  by  Poisoning  treated  by 
Cocaine,  and  Affections  of  the  Stomach,  Tetanus,  Skin  Disease. 

Cocaine  in  Gastritis  Produced  by  Poisoning-. 

In  a  recent  case  published  by  a  physician*  in  Scranton,  Pa., 
a  young  girl,  after  an  unsuccessful  attempt  at  suicide  by  laud- 
anum, took  "Rough  on  Rats."    She  was  given  ipecac  and 

*  Dr.  J.  Emmet  O'Biien. 


76  ARTIFICIAL  ANAESTHESIA. 

sulphate  of  ziuc,  also  large  quantities  of  dialized  iron  and  lime 
water.  Two  grains  of  morphine  were  administered  hypoder- 
matically  in  divided  doses  during  the  night,  and  the  woman 
was  kept  anaesthetized  by  means  of  chloroform  and  ether  for 
twelve  hours.  Whenever  the  anaj-thetic  was  withdrawn,  the 
patient  would  rebel,  and  was  with  difficulty  held  by  three  per- 
sons when  not  profoundly  under  the  influence  of  ether.  Twelve 
hours  after  the  poison  had  been  taken,  the  girl  was  still  in  ter- 
rible agony,  and  showed  signs  of  collapse.  It  was  suggested 
by  another  physician  that  over  half  an  ounce  of  a  four  per 
cent,  solution  of  cocaine  hydrochlorate  (about  ten  grains) 
should  be  administered,  it  being  supposed  that  all  the  arsenic 
had  been  vomited  or  neutralized,  and  that  gastritis  had  set  in. 
In  a  few  minutes  the  patient  ceased  to  complain  of  her  stom- 
ach, the  mania  subsided,  and  the  anaesthesia  was  discontinued. 
The  pulse  grew  stronger,  and  the  woman  was  soon  able  to 
walk  with  assistance. 

Cocaine  in  Affections  of  the  Stomach. 

Cocaine  has  been  found  most  useful  in  certain  affections  of 
the  stomach.  From  the  researches  and  clinical  observations 
we  arrive  at  the  following  conclusions:  1.  That  cocaine  exerts 
on  the  mucous  membrane  of  the  stomach,  and  that  of  the  di- 
gestive tube,  an  action  as  certain  as  on  the  external  raucous 
membranes;  2.  That  for  this  action  to  be  as  complete  as  pos- 
sible, one  must  facilitate  the  impregnation  of  the  gastric  and 
intestinal  mucous  membranes  by  promoting  their  secretions. 
Hence  the  advantage  of  associating  cocaine  with  alkalies.*  For 
the  action  to  attain  its  maximum  duration,  one  mast  add  to 
this  mixture  very  small  doses  of  morphine. 

Cocaine  in  Persistent  or  Uncontrollable  Vomiting:. 

From  the  peculiar  action  of  cocaine  upon  mucous  mem- 
branes and  vascular  tissue,  it  was  supposed,  theoretically,  to 
be  capable  of  diminishing  the  sickness  of  pregnancy  and  other 
severe  irritation  of  the  stomach  of  a  reflex  character.  It  has 
been  tested  in  a  number  of  cases  with  more  or  less  success. 

*  It  must  be  remembered  that  caustic  alkalies  decompose  the  cocaine. 


COCAINE.  77 

Cocaine  in  Liavage  or  Gavage. 

In  the  act  of  inserting  the  stomach  pump  or  tube,  there  is 
almost  always  pain  and  spasm,  due  to  the  contractions  which 
take  place  on  the  isthmus  of  the  fauces,  which  may  be  obviated 
by  painting  with  a  two  per  cent,  solution  of  cocaine.  It  has 
been  found  very  valuable  in  certain  spasmodic  and  even  per- 
manent stricture  of  the  oesophagus;  where  dilatation  is  re- 
quired, a  two  per  cent,  ointment  is  applied  to  the  tube. 

Cocaine  in  Boulimie  or  Insatiable  Hung^er. 

This  peculiar  intense  and  insatiable  hunger  or  canine  appe- 
tite is  peculiar  to  pregnancy,  and  can  in  some  cases  be  relieved 
by  small  doses  of  hydrochlorate  of  cocaine,  ^V  *o  tV  or  even  i 
of  a  grain  taken  at  intervals,  in  pill  form,  while  in  the  recum- 
bent posture. 

Tetanus  treated  by  Morphia  and  Cocaine. 

Lopez  is  quoted  by  the  Journal  of  Nervous  and  Mental  Dis- 
eases, for  December,  1887  {Medical  News,  January  28,  1888),  as 
reporting  in  an  Italian  journal,  the  following  case :  M.  G.,  fifty 
years  old,  having  worked  in  the  cold  and  wet,  complained  of 
rheumatic  pains  in  the  back  and  extremities.  Three  days 
after,  he  had  an  attack  of  opisthotonus,  painful  spasms,  and 
all  the  symptoms  of  idiopathic  tetanus.  Morphine  and  chlo- 
ral hydrate  were  prescribed.  For  three  days  the  patient,  under 
the  influence  of  these  medicines,  had  little  pain ;  but  there 
was  increased  muscular  rigidity  and  spasms.  At  last  he 
was  unable  to  swallow,  and  death  was  believed  imminent. 
Injections  of  morphine  were  without  effect.  Then  the  writer 
injected  three  syringefuls  of  a  mixture  of  morphia  and  cocaine, 
five  per  cent,  of  each.  The  effect  was  immediate.  After  two 
hours  he  could  move  the  extremities,  open  his  mouth  and  turn 
himself  in  bed.  The  next  day  he  continued  to  improve.  There 
remained  a  slight  trismus,  and  a  little  rigidity  of  the  neck.  A 
quarter  of  a  syringeful  of  the  same  solution  was  injected  in 
each  side  of  the  neck,  and  the  day  after  all  the  symptoms  had 
disappeared. 


78  ARTIFICIAL   ANAESTHESIA. 

Cocaine  in  Skin  Diseases. 

Lustgarten  {Wiener  Med.  Wochenschri/t,  November  12,  1887) 
states,  what  we  demonstrated  soon  after  cocaine  was  discov- 
ered, that  where  the  epidermis  is  in  contact,  cocaine  applied 
to  the  skin  is  not  absorbed ;  but  where  the  horny  layer  is  thin, 
absent  (removed  by  alkalies,  alcohol  or  chloroform),  it  acts. 
A  two  per  cent,  solution  used  several  times  daily,  allays  the 
itching  in  acute  and  sub-acute  eczema,  being  especially  valua- 
ble in  eczema  of  the  anus  and  genital  regions  of  both  sexes. 
In  the  form  of  ointment  he  employs  oleate  of  cocaine,  from  6 
to  15  grains ;  lanolin,  4^  drachms ;  followed  by  the  use  of  a 
dusting  powder  (two  of  the  best  are  finely-powdered  talc  or 
lycopodium).  In  pruritis  ani,  suppositories  may  be  made  con- 
taining three-fourths  of  a  grain  of  oleate  of  cocaine.  The 
author  cautions  against  the  toxic  effects  of  cocaine,  three  cases 
of  this  kind  having  been  encountered  when  only  three-fourths 
of  a  grain  had  been  used. 

Treatment  of  Chilblain. 

Apply  with  cotton  or  wool  a  four  per  cent,  solution  of  co- 
caine for  ten  minutes ;  then  remove  the  cotton,  and  cover  the 
parts  with  compound  tincture  of  benzoin.  This  repeated  a 
few  times  will  entirely  relieve  the  pain  and  irritation.  A 
valuable  ointment  for  the  same  disease  is  equal  parts  of  oil  of 
turpentine  and  compound  rosin  ointment.  Apply  by  rubbing 
in  the  ointment  near  a  hot  fire  at  bed-time.  Another  salve  is 
recommended  by  Dr.  Lassar : 

R     Acid  carbolic  cryst gr.  xv. 

Ung.  plumbi ^v. 

Lanolin aa ^iiss. 


Oil  Amygdal.  ^     _    ^  ^ ^^  ^^ 

Oil  lavend. 


Cocaine  in  Intense  Itcliing  of  the  Skin. 

In  the  various  forms  of  pruriginous  affections  of  the  skin, 
cocaine  with  vaseline  or  a  two  per  cent,  solution  in  alcohol 
will  allay  the  distressing  itching  of  the  skin. 


COCAINE.  79 

Cocaine  in  Burns. 

Either  the  solution  or  ointment  of  cocaine  has  the  great 
advantage  of  dissipating  the  intense  pain  of  severe  burns  when 
in  a  two  per  cent,  solution. 

Cocaine  in  Anal  or  Vulval  Pruriency  or  Painful 
Herpes. 

R     Cocaine  oleat.  .   .    .  40  to  J  gramme  (gr.  viiss.  to  xvss), 

Lanolini 18  grammes  (5  v.). 

01.  oliv 2  grammes  (gr.  xxxi.). 

To  be  used  several  times  a  day. 
— Gaz.  Hebe,  des  Sci.  Mede.,  Montpellier,  Jan.  14,  1888. 

Cocaine  in  Cracked  Nipples. 

A  two  per  cent,  powder  of  hydrochlorate  of  cocaine  and 
starch,  applied  to  the  fissure  in  the  nipple  of  nursing  women, 
covered  with  collodion,  will  relieve  the  distressing  pain.  The 
same  good  results  follow  fissures  of  the  skin  of  the  hands  du- 
ring very  cold  weather.  A  few  inveterate  cases  require  first  to 
touch  the  fissure  with  a  fine  pencil  of  nitrate  of  silver,  very 
gently. 


CHAPTER  VIII. 

Cocaine  in  Acute  Catarrh,  Coryza,  or  Cold  in  the  Head,  Hay  Fever, 
Whooping-Cough,  Pharyngitis,  Paroxysmal  Sneezing,  Asthma. 

Cocaine  in  Acute  Catarrh,  Coryza,  or  Cold  in  the 
Head. 

In  acute  catarrh,  or  cold  in  the  head,  we.  have  a  condition  of 
engorgement  of  the  blood-vessels  in  the  nasal  mucous  mem- 
brane, and  the  secretion,  which  at  first  is  thin  and  watery 
through  hyperstimulation  of  the  glands,  soon  becomes  more 
charged  with  broken-down  epithelial  cells,  lymph  corpuscles, 
pus  globules,  etc.,  until  it  assumes  the  character  of  thick, 
tenacious  mucus,  or  muco-pus.  If  cocaine  be  applied  early  to 
the  membrane  in  a  case  of  acute  coryza,  its  constringing  influ- 
ence on  the  membrane  must  diminish  the  blood  supply,  and 


80  ARTIFICIAL   ANAESTHESIA. 

thus  prevent  the  engorgement  and  transudation.  We  have 
tested  its  abortive  action  in  an  attack  of  coryza  occurring  in 
ourselves. 

As  soon  as  the  initial  stage  has  passed  over,  and  secretion 
commenced,  a  four  per  cent,  solution  should  be  applied  freely 
over  the  interior  turbinated  bones  of  each  side. 

As  is  well  known,  the  coryza  of  nursing  infants  and  young 
children  may,  by  preventing  suckling,  prove  a  very  serious 
affection.  It  can  be  cured,  however,  by  the  introduction  into 
the  nasal  cavity,  six  times  daily,  of  a  one  per  cent,  solution  of 
the  hydrochlorate  of  cocaine  on  cotton  for  live  minutes.  Ac- 
cording to  the  author,  children  who  previously  had  obstinately 
refused  to  nurse,  will  commence  to  suckle  a  few  minutes  after 
the  first  application  of  the  cocaine,  and  the  coryza  is  ordina- 
rily cured  after  about  four  days  of  this  treatment.* 

B     Hydrochlorate  of  cocaine 2  g^^. 

Very  finely  powdered  starch 49  grs. 

Mix  intimately. 
SiG. — Use  at  intervals  of  about  an  hour  until  relieved. 

Cocaine  in  Hay  Fever. 

Sir  Andrew  Clark  prefers  to  use  a  solution  of  five  per  cent., 
applying  it  to  the  interior  of  the  nose  and  back  of  the  soft 
palate,  by  means  of  a  large  camel's-hair  pencil  attached  to  an 
aluminium  shank,  and  bent  at  an  appropriate  angle.  For  use 
in  the  form  of  nasal  bougies,  a  quarter  of  a  grain  or  more  of 
the  hydrochlorate  of  cocaine  is  dissolved  in  a  mixture  of 
gelatine  and  glycerine,  and  made  of  different  weights  and 
shapes,  according  to  the  peculiarities  of  the  case  on  which 
they  are  to  be  employed. 

Cocaine  and  Phosphate  of  Lime  in  Laryngeal 
Tiihercnlosis. 

Professor  John  Schnetzler  used  phosphoric  acid  in  different 
degrees  of  concentration,  and  even  in  full  strength,  applied  by 
means  of  a  brush  or  the  syringe  to  the  larynx,  producing  pain 

♦  This  treatment  is  made  more  6uccessful  by  the  spray  of  the  antiseptic  tablets  of 
Dr.  Seller  ;  also  useful  in  hay  fever  to  cleanse  the  parts. 


COCAINE.  81 

in  some  cases,  which  he  obviates  by  the  use  of  the  following 
powder : 

R      Cocaine  mur 0.1  (gram). 

Calci.  phosphor 100 

01.  Menth.  pip gtt  v.  M. 

Use  by  iusuiBations. 

Though  the  remedy  has  no  specific  influence  on  the  tuber- 
cular process,  relief  (and  under  favorable  conditions  also  re- 
covery) has  been  obtained  in  several  cases ;  it  is  also  an 
excellent  remedy  in  all  catarrh  affections  of  the  upper  air 
passages. — Jour.  Am.  Med.  Association,  Jan.  21,  '88. 

Cocaine  in  Whooping-Cough. 

Dr.  Weintraub,  of  Eydknhuen,  prescribes  the  following 
formula,  with  good  results  : 

R     Cocin  muriat gr.  j.  J  to  1  gr. 

Aqu.-amygd.   amar ^iiss.  M. 

SiG. — Ten  to  fifteen  drops  several  times  a  day. 

—Alg.  Med.  Central  Ztg.,  91,  1887. 

Cocaine  and  Resorcin  in  Wliooping-Coiig-h. 

Eesorcin  has  been  found  one  of  the  most  available  reme- 
dies in  pertussis,  relieving  in  the  bacterial  origin  of  the  dis- 
ease. Since  1885,  cocaine  has  been  used  as  a  preliminary  to 
the  resorcin,  as  he  found  that  it  lessened  the  intensity  and 
frequency  of  the  cough  before  the  resorcin  had  time  to  destroy 
the  morbific  germs.  We  use  a  four  per  cent,  solution  and  an 
eight  per  cent,  solution  of  resorcin  ;  and  this  combination  con- 
stitutes the  best  treatment  for  whooping-cough  now  at  our 
command. 

Cocaine  Mixture  for  Relief  of  Coiigli  and  of  Chronic 
Pliai'yngitis. 

The  following  formula  has  been  recommended  for  the  relief 
of  the  cough  in  chronic  pharyngitis : 

R     Cocaine ,    .    .  gr.  iss 

Glycerine f,^i- 

4^ 


82  ARTIFICIAL  ANESTHESIA. 

Aquffi  (lest f^x  gii. 

Acid  carbo! gi'-  i- 

Sio. — Apply  morning  and  evening  with  a  suitable  brush. 

— Medical  News,  April  11,  '85. 

Cocaine  by  Insufflation  and  Inhalation. 

A.  Inhalation. 

R     Cocaine  hydrochlor gr.  iij. 

Potasaii   chlorat 3  "• 

Aquae  laurocerasi f  ^  xii.  M. 

B.  Insufflation. 

R     Cocaine  hydrochlorat gr.  i. 

Morphiffi  hydrochlorat gr.  i. 

Bismuth  sub-nitrate 

Sacch.  alb aa  .    .    ,    .  ^i.  ij. 

Cocaine  in  Paroxysmal  Sneezing-. 

U     Sol.  of  hydrochlorate  of  cocaine  (4  per  cent.)  ^i. 

Acid  carbolic ^\. 

Tinct.  camphora ^iss. 

Aquse ^ii.       M. 

Lotion.  Syringe  or  spray  the  nostrils  each  morning  with  posterior 
nasal  syringe  or  spray  apparatus. 

Dr.  Da  Costa  {Med.  and  Surg.  Reporter,  Nov.  7, 1885),  having 
found  solutions  of  cocaine  favorable  in  rose  cold  or  hay  fever, 
concludes  as  follows :  That  the  remedy  is  not  radical  and, 
strictly  speaking,  curative.  He  has  found  that  it  gives  great 
comfort,  converts  severe  into  light  cases,  enables  them  to  remain 
in  their  homes  who  otherwise  are  obliged  to  flee  to  hay  fever 
resorts,  and  relieves  much  suffering  and  distress. 

After  the  suffering  and  distress  are  relieved  by  the  cocaine, 
we  have  found  permanent  relief  from  the  spray  of  a  solution 
of  peroxide  of  hydrogen,  one-half  ounce  to  half  a  pint  of 
pure  water.  The  spray  apparatus  must  be  of  glass  or  rubber, 
as  all  metallic  contact  destroys  the  per  oxide  of  hydrogen. 

Cocaine  in  Astliina. 

Hosier,  of  Greefswald  {Birin.  Med.  Review,  p.  236,  Nov., 
1886),  points  out  that  cocaine  has  a  central  as  well  as  a  periph- 


COCAINE.  83 

eric  local  action  on  the  sensory  nerve  endings,  and  this  central 
action  is  at  first  stimulating,  but  afterward  sedative  or  narcotic. 
By  both  these  reactions  cocaine  ought  to  be  of  use  in  asthma. 
Beschorner  has  published  two  cases  in  which  it  was  of  service, 
and  Hosier  in  three  cases  has  obtained  excellent  results.  All 
these  were  uncomplicated,  and  occurred  in  young  people  of 
twenty-three  to  twenty-five  years  of  age.  The  drug  was  given 
subcutaneously  in  two  per  cent,  solution. 


CHAPTEE    IX. 

Cocaine  in  Diseases  of  the  Eye  and  Ear. 

The  best  antiseptic  solution,  containing  a  minute  quantity 
(gr.  su^ttt)  of  bichloride  of  mercury,  may  be  employed  after 
keeping  a  few  days,  if  made  with  pure  distilled  water.  The 
injurious  results  which  were  published  *  from  the  use  of  hydro- 
chlorate  of  cocaine  in  the  practice  of  Drs.  Keyser  and  Straw- 
bridge,  were  owing  either  to  the  impurities  in  the  solution  or 
to  its  being  too  strong.  I  have  found  that  a  strong  solution 
will  cause  a  feeling  of  roughening  and  will  detach  the  epithe- 
lium of  the  eye.  This  will  require  an  infusion  of  pith  of  sas- 
safras, with  camphorated  tincture  of  opium  (a  teaspoonful  in  a 
coffee  cup  of  the  tea),  to  relieve  the  disagreeable  symptoms. 
The  following  is  an  extract  from  Dr.  Keyser's  letter  and  his 

mode  of  using  cocaine : 

"  November  29,  1886. 

"I  have  had  no  further  mishaps  with  cocaine,  and  use  it  constantly 

for  everything.     I  use  only  a  2  per  cent,  solution,  and  have  it  made 

in  a  saturated  solution  of  boric  acid."  f 

The  question  of  using  a  freshly-prepared  solution  is  of  the 
utmost  importance.  Cases  of  irritation  and  inflammation  often 
occur  after  using  solutions  too  strong  or  containing  mould.  Like- 
wise the  syringe  must  be  kept  scrupulously  clean,  and  after  wash- 

*  The  New  Anaesthetic,  etc.  By  Laurence  Turnbull,  pp.  53.  Pamphlet  of  76 
pages,  published  by  P.  Blaklston,  Son  &  Co.,  Philadelphia,  1885. 

f  The  only  objection  to  the  boric  acid  is  that  the  variety  of  mould  termed  penicil- 
lum  will  very  soon  form  in  the  solution,  unfitting  it  for  use,  unless  made  fresh  each 
time  it  is  employed. 


84  ARTIFICIAL  ANAESTHESIA. 

ingand  wiping,  draw  a  few  drops  of  equal  parts  of  olive  oil  and 
liquid  carbolic  acid  up  and  down  the  needle,  then  wipe  it  dry. 

Cocaine  in  Diseases  of  the  Eye. 

Five  cases  of  ordinary  catarrhal  conjunctivitis  were  treated 
successfully,  but  not  worthy  of  being  reported  in  detail. 

Case  Sixth.  Case  of  clyoUtis,  in  a  young  lady  of  sixteen,  C. 
G.,  at  school,  with  extreme  pericorneal  congestion.  The  pain 
in  the  eye  was  very  much  relieved  by  dropping  in  a  2  per  cent, 
solution  of  the  hydrochlorate  of  cocaine,  and  congestion  dis- 
appeared as  if  by  magic.  She  was  directed  colored  glasses 
and  not  to  use  her  eyes;  when  the  pain  returned,  to  drop  in 
one  or  two  drops  of  the  same  solution. 

Case  Seventh.  A  gentleman,  T.  L.,  aged  sixty  years,  with 
catarrhal  conjunctivitis,  which  attacks  him  during  autumn  and 
remains  most  of  the  winter,  increased  by  cold  winds  and  read- 
ing by  gaslight.  He  was  suffering  from  a  discharge  in  the 
morning  and  burning  through  the  day.  I  applied  a  2  per 
cent,  solution  to  the  eye  with  a  brush,  when  he  complained  of 
a  smarting  for  a  few  seconds,  but  much  less  than  a  former 
solution,  which  was  made  with  alcohol  and  water.  (McKesson 
&  Robbins'  solution  is  more  agreeable,  containing  a  minute 
percentage  of  salicylic  acid  which  keeps  and  makes  it  anti- 
septic.) After  the  smarting  had  disappeared,  he  bore  without 
flinching  a  solution  of  boro-glyceride,  to  get  rid  of  the  exces- 
sive secretions  which  blurred  his  vision  at  night.  It  also  re- 
moved the  red  and  irritable  appearance  of  the  edges  of  the 
eyelid. 

Case  Eighth.  This  case  is  similar  to  No.  6,  only  in  a  lady  of 
39,  who  has  a  great  deal  of  writing  to  do,  and  is  employed  in 
a  book-bindery  ;  but  a  few  applications  of  the  2  per  cent,  solu- 
tion relieved  her. 

In  two  of  the  eye  cases,  dilatation  of  the  pupil  took  place; 
but  not  for  some  time  after  full  application ;  it  caused  slight 
dryness,  but  did  not  interfere  with  the  vision. 

Case  Ninth.  Case  of  acute  coryza,  without  pain,  but  sneezing, 
complained  that  when  the  solution  was  applied  by  means  of  a 
dropper  it  caused  her  pain,  but  there  was  no  return  of  painful 


COCAINE.  85 

sneezing,  which  is  in  certain  families  the  forerunner  of  the 
swelling  of  the  mucous  membrane  with  cold  in  the  head. 

Case  Tenth.  A  gentleman  aged  37,  who  has  a  broken  nose 
and  a  hyperti'ophic  catarrh  on  very  slight  exposure,  was  at- 
tacked on  the  evening  of  the  23d  of  January,  with  great  op- 
pression. Having  to  ride  in  the  country  in  an  open  carriage 
and  stand  in  mud  and  ice  for  some  hours,  he  returned  in  the 
evening  with  a  feeling  of  great  distress,  and  pain  in  his  head, 
and  mucous  membrane  of  the  nasal  passages  much  swollen. 
Two  applications  of  a  2  per  cent,  solution  of  the  hydrochlorate 
to  the  whole  surface  of  the  posterior  nares  at  intervals  of  five 
minutes,  followed  with  a  5  per  cent,  solution  of  the  alkaloid  in 
oleic  acid,  gave  him  great  relief,  so  that  he  could  breathe  and 
blow  with  comfort  and  satisfaction.  He  was  then  directed  i 
grain  of  morphia  sulphas,  and  one-hundredth  of  atropine,  to 
be  taken  at  bed-time. 

24th,  Still  suffering  somewhat  from  the  difficulty  of  the 
breathing  through  the  nostrils,  but  a  repetition  of  the  applica- 
tion of  the  oleate  relieved  him  entirely. 

Jan.  26.  Discharged  the  patient,  cured. 

Jan.  27.  Case  Eleventh.  Catarrhal  inflammation  of  the  eye- 
lids, known  as  Blepharitis  Marginalis,  with  defective  vision,  in 
a  school  girl,  aged  10  years.  The  crusts  around  the  eyelids 
were  removed  twice  with  a  warm  2  per  cent,  solution  of  co- 
caine, after  resting  for  a  time;  then  the  eyelids  were  painted 
with  a  solution  of  boro-glyceride ;  these  two  preparations  used 
together  entirely  removed  the  redness  and  gave  great  relief  to 
the  little  patient.  She  was  directed  to  continue  the  use  of  the 
solution  of  boro-glyceride  for  some  time,  not  to  use  her  eyes, 
and  wear  smoked  glasses  when,  in  the  sun. 

Cocaine  in   the  Treatment    of   Gronorrlioeal   Opli- 
tlialmia. 

Mr.  A.  Leahy  reports  (in  the  Indian  Med.  Gazette,  July, 
1886)  two  cases  of  gonorrhceal  ophthalmia,  in  both  of  which 
the  greatest  benefit  was  derived  from  application  of  cocaine. 
As  it  is  well  known,  in  gonorrhceal  ophthalmia  it  is  of  primary 
importance  to  lessen  the  inflammation  rapidly,  to  relieve  the 


SQ  ARTIFICIAL   ANESTHESIA. 

intense  congestion  of  the  conjunctival  vessels  and  reduce 
chemosis,  and  by  so  doing  prevent  ulceration  and  sloughing  of 
the  cornea.  Last,  but  not  least,  is  the  relief  of  the  ocular  and 
circum-orbital  pain,  which,  by  its  persistence,  greatly  depresses 
the  patient  and  prevents  sleep.  Mr.  Leahy  employed  a  mix- 
ture composed  of  one-half  grain  of  sulphate  of  atropine  and 
four  grains  of  sulphate  of  cocaine  incorporated  with  100  grains 
of  vaseline.  This  mixture  was  introduced  beneath  the  upper 
eyelids;  and  after  three  days' treatment  the  chemosis  rapidly 
became  less,  the  discharge  diminished  in  quantity,  the  pain 
completely  disappeared,  and  the  cornea,  which  had  been  hid- 
den by  the  chemosis,  became  visible. 

Cocaine  and  Ati'opia  for  Iritis. 

Guaiaila  gives  the  following  as  used  by  many  ophthalmolo- 
gists : 

R       Cocaine  hydroclilor gr.J. 

Atrop.  sulphat gr.l. 

Acid  boric gr.iv. 

AqucB  destillat ^iiss.      M. 

Sio. — One  or  two  drops  in  the  eye  every  half  hour  until  the  pupil 

dilates. 

— Uunion  Medicale,  June  25,  1887. 

On  the  Use  of  the  Sokition  of  Cocaine  Hydrochlo- 
rate  in  Ear  Disease. 

Nov.  20,  G.  B.  M.,  M.D.,  applied  for  deafness  in  both  ears, 
but  especially  the  right.  On  examination  found  the  sides  of 
meatus  and  lumen  filled  with  separated  masses  of  scales  several 
millimeters  in  length,  firmly  attached  to  the  parts,  which  on 
removal  by  the  forceps  gave  him  great  pain.  He  also  found 
the  pressure  of  the  ear  speculum  painful.  This  was  explained 
after  the  removal  of  a  portion  of  these  diseased  scales  by  find- 
ing the  under  .surface  inflamed,  reddened  and  ready  to  bleed  at 
the  slightest  touch  of  the  instrument.  To  obviate  this  pain  and 
allow  the  entire  removal  of  this  desquamated  material,  a  4  per 
cent,  solution  of  hydrochlorate  of  cocaine  was  instilled  into  the 
ear  every  five  minutes  for  fifteen  minutes.    At  the  end  of  this 


COCAINE.  87 

period,  again  began  removing  the  offending  material  with- 
out so  much  pain ;  still  it  was  not  a  true  anaesthesia,  and  if  we 
made  strong  pressure  with  the  speculum  in  introducing  it,  it 
also  gave  him  slight  pain ;  still  he  was  able  to  bear  it  much 
better  with  the  solution,  until  all  was  removed  from  the  right 
ear.  He  was  then  directed  a  sol.  zinci  sulpho-carbolate,  grs. 
iv ;  morphia  sulphas,  grs.  i ;  iv.  oz.  of  aqua  destillata.  For 
the  left  ear,  after  the  use  of  the  forceps,  gave  an  alkaline  solu- 
tion to  drop  in  ten  drops  3  or  4  times  a  day  and  rest  for  fifteen 
minutes  so  as  to  remove  what  scales  were  on  the  m.  tympani. 
November  23,  washed  out  the  remaining  scales,  and  inflated 
the  middle  ear,  with  great  improvement  of  hearing  in  both  ears. 

Nov.  25,  H.  F.  M.,  aged  29,  bank  clerk,  suffering  from  deaf- 
ness and  constant  "rattling  or  buzzing,"  from  congestion  and 
hypertrophy  of  the  pharyngeal  tonsils  and  mucous  membrane 
of  the  post-nasal  spaces,  which  required  cutting  freely  with  a 
tenotomy  knife.  Before  doing  so,  I  applied  a  4  per  cent,  solu- 
tion of  the  cocaine,  and  although  I  made  five  different  inci- 
sions into  the  enlargement,  he  was  not  aware  that  it  was 
accomplished  until  he  found  a  few  drops  of  blood  passing  into 
his  oesophagus.  One  week  after  he  reported  by  letter  of  im- 
provement in  hearing.  In  this  operation  not  one-fourth  the 
amount  of  blood  was  lost  as  in  such  cases  without  the  cocaine, 
the  parts  remaining  quite  rigid  for  some  time  after  the  operation. 

November  29.  Applied  the  4  per  cent,  solution  to  a  lady 
suffering  from  excessive  secretions  of  glands  of  the  throat,  and 
passing  into  the  Eustachian  tube  causing  noises  of  a  variable 
character.  She  suffered  also  from  swelling  and  hypertrophic 
conditions  of  the  posterior  portion  of  the  nasal  mucous  mem- 
brane and  turbinated  bodies.  The  parts  were  cleansed  with 
spray  of  Dobell's  solution,  and  a  strong  current  of  dry  con- 
densed air  was  employed  to  free  them  from  moisture,  a 
flexible  silver  catheter  was  introduced  first  into  the  right  side 
of  the  nose  and  a  nozzle  was  fitted  to  it,  and  then  the  elastic 
tube  of  the  condensed  air  chamber,  and  a  few  drops  of  the 
solution  of  hydrochlorate  of  cocaine  were  introduced  into  the 
catheter,  and  the  parts  sprayed  by  forcing  the  air  through  it. 
In  the  same  operation  performed  upon  the  opposite  ear,  there 


88  ARTIFICIAL   ANESTHESIA. 

being  a  deviation  of  the  septum,  there  was  more  pain,  but 
very  much  less  than  when  we  introduced  the  instrument  be- 
fore. The  spraying  was  repeated  at  three  different  times, 
when  in  about  ten  minutes  she  felt  the  peculiar  apparent 
swelling  and  drying  effects,  and  great  relief  from  the  noises, 
by  the  freedom  with  which  air  passed  through  the  Eustachian 
tubes.  The  lady  reported,  a  week  after,  improvement  of  hear- 
ing and  more  freedom  from  the  noises. 

On  the  same  day  a  patient,  W.  C.  D.,  aged  16,  suffering  from 
the  peculiar  sniffling  from  swelling  of  the  mucous  membrane 
of  the  nasal  cavities,  from  what  was  termed  "  a  cold  in  the 
head,"  was  relieved  by  painting  the  parts ;  three  applications 
of  a  4  per  cent,  solution  reduced  the  swelling  as  if  by  magic. 

Nov.  30,  C.  E.  W.,  aged  21,  a  case  similar  to  the  one  de- 
scribed above,  but  the  stuffing  and  sniffling  more  intense  and 
distressing,  was  treated  in  a  similar  manner,  but  before  I  ap- 
plied the  cocaine,  the  parts  were  cleansed,  through  the  nose 
and  throat,  by  Dobell's  solution,  and  slightly  stimulated  by  a 
spray  of  a  diluted  tincture  of  galangula.  The  only  addition 
was  that  a  4  per  cent,  solution  of  cocaine  was  directed  to  be 
employed  at  home,  so  as  to  rid  him  promptly  of  this  disagree- 
able feeling.  He  reported  December  7th,  and  13Lh,  feeling 
greatly  relieved. 

December  3,  D.  C.  M.,  West  Virginia,  applied  with  a  history 
of  acquired  syphilis  by  inoculation  several  years  ago,  in  the 
finger  from  an  obstetric  case.  There  were  two  points  of  ulcer- 
ation of  the  mucous  membrane  of  the  naso-pharynx,  one  and  a 
half  inches  above  the  edge  of  the  soft  palate,  and  one  behind 
the  right  tonsil,  with  enlargement  of  the  gland  and  discharge 
of  pus.  After  drying  the  parts  with  absorbent  cotton,  we  in- 
troduced a  4  per  cent,  solution  of  cocaine,  up  and  back  into  the 
point  of  ulceration,  and  applied  the  crystal  of  chromic  acid  to 
the  first  ulcer  without  the  slightest  pain. 

December  4.  After  cleansing,  again  applied  the  solution, 
and  introduced  a  delicate  Eustachian  forceps,  with  a  pledget 
of  cotton  wool  charged  with  pure  powdered  sulphate  of  copper, 
to  the  second  ulcer,  which  bled  on  being  touched,  but  without 
giving  the  patient  any  pain.     December  5,  made  a  third  appli- 


COCAINE.  89 

cation  with  more  freedom;  no  blood  followed,  and  he  stated 
he  had  seen  no  pua  since  the  first  application. 

Directed  to  spray  the  part  with  the  mercuric  chloride,  one 
tablet  to  make  a  one  one-thousandth  of  a  grain  solution  dis- 
solved in  a  pint  of  distilled  water,  also  to  use  internally  after 
meals  a  tablespoonfui  of  elixir  of  coca  (strength  20  grains  ex- 
tract of  coca  to  the  ounce). 

Deafness  from  Coryza. 

This  form  of  deafness  is  directly  traceable  to  nasal,  naso- 
pharyngeal or  pharyngeal  disease  of  the  lining  membrane. 

The  openings  of  the  Eustachian  tubes,  which  lead  directly 
to  the  middle  ear,  are  to  be  found  just  above  and  in  front  of  the 
tonsils,  and  behind,  and  lying  close  to  the  posterior  nares  or 
openings  of  the  nose.  As  the  orifices  of  these  ducts  are 
■widely  opened  every  time  we  swallow,  it  can  be  seen  how 
readily  mucous  and  muco-purulent  matter  from  the  nose  and 
throat,  in  case  of  inflammation  or  acute  or  even  chronic 
coryza  existing,  may  enter  and  light  up  an  inflammation  of  its 
lining  membrane,  which  will  in  some  cases  extend  to  the  deli- 
cate structures  of  the  middle  ear.  Plugging  of  the  openings  of 
these  tubes,  viewed  from  a  purely  mechanical  stand-point,  will 
certainly  cause  or  aggravate  deafness.  Hence  it  is  of  the 
utmost  importance  that  prompt  and  efiicient  means  should  be 
used  in  order  to  relieve  the  patient,  and  ultimately  to  cure  the 
disease,  so  as  to  prevent  and  cure  the  deafness.  This  deafness 
is  sure  to  follow  or  be  increased  by  these  recurring  attacks, 
the  result  of  cold  air  applied  to  the  moist  skin  of  any  part  of 
the  body.  The  application  of  a  four  per  cent,  solution  of  the 
hydrochlorate  of  cocaine  to  the  nose  will  cause  the  swelling 
from  acute  coryza  to  disappear  for  hours,  and  if  repeated  two 
or  three  times  will  entirely  relieve  the  occlusion  of  the  nostril, 
and  check  the  discharge  (see  cases  reported).  If  the  case  is  a 
chronic  one,  with  hypertrophy  of  the  nasal  mucous  membrane, 
it  causes,  when  applied,  a  most  remarkable  change  of  color 
and  contraction  of  the  swollen  tissue.  The  great  advantage  of 
this  local  anaesthetic,  as  we  have  shown,  is  that  when  necessary, 
we  are  able  to  apply  local  remedies  without  pain  of  a  more 
potent  character  (see  also  cases  reported). 


90  ARTIFICIAL   ANAESTHESIA. 

More  recent  information,  and  various  trials,  have  caused  us 
to  modify  our  opinion  in  regard  to  the  use  of  a  hot  four  per 
cent,  solution  of  the  hydrochlorate  of  cocaine,  in  relieving  pain 
in  the  ear  prior  to  perforation  of  the  membrana  tympani. 
We  have  received  several  cases  of  the  history  of  acute  at- 
tacks of  myringitis  or  neuralgia  of  the  ear,  from  most  reliable 
sources;  two  of  these  cases  we  had  the  opportunity  of  seeing, 
after  being  relieved  temporarily  (for  two  hours),  and  which 
were  not  examined  at  the  time  when  the  application  was 
made.  When  the  cases  were  seen,  we  found  that  a  discharge 
had  followed  the  same  evening,  and  perforation  of  the  mem- 
brane had  taken  place  in  both  cases.  It  is  a  well-known 
fact,  that  prior  to  perforation  there  is  an  elevation  of  the 
cuticular  layer,  with  a  softening  process,  whereby  any  liquid 
applied  to  the  part  might  pass  in  by  imbibition,  and  influence 
the  sodden  layers  of  the  membrana  tympani,  and  if  it  had 
anaesthetic  properties,  would  impress  the  branch  of  the  chorda 
tympani  nerve,  and  relieve  pain. 

We  have  since  extended  its  use  to  ear  cases,  with  subjective 
aural  sounds,  as  in  the  peculiar  form  of  ear  disease  depending 
on  pressure  affecting  the  labyrinth,  first  upon  the  tympani 
and  handle  of  the  malleus,  extending  to  the  stapes  and  fenestra 
ovalis,  and  also  from  other  causes,  such  as  shortening  from 
contraction  of  the  tensor-tympani,  or  in  irritation  of  the 
pharyngeal  mucous  membrane  propagated  through  the  Eu- 
stachian tube  to  the  tympanum  or  middle  ear,  or  from  spasm 
of  the  muscles  or  temporary  hypersemia.  It  would  not,  in  all 
cases,  permanently  remove  these  sounds,  only  relieve  them  in 
intensity,  especially  if  from  tympanic  adhesion  or  anchylosis 
of  the  joints  of  the  ossicles  o/"  <Ae  ear.  These  latter  cases  are 
to  be  treated  by  the  exhauster  of  Seigle,  or  Woakes,  of  London. 


ETHER   AS   A    LOCAL   ANAESTHETIC. 


91 


CHAPTER    X. 

Local  Anaesthetics — Oil  of  Eucalyptus,  Ether,  Rhigolene,  Methyl 
and  its  Chloride,  Hydrastine,  Homatropine  and  Ephedrine,  Bru- 
cine,  Lewenin,  Apomorphine,  Drumine,  Gledelschine,  Erythro- 
phleine,  Caffeine,  Helleborinc,  Canadol,  Menthol,  Iodoform,  lodol, 
Bromide  of  Ethyl  and  Potassium,  Carbolic  Acid,  Quinine,  Anti- 
pyrine,  Antifibrin. 

Having  given  briefly  the  most  important  results  of  the  re- 
cent observations  and  experiments  with  cocaine,  I  now  pass  to 
the  second  part  of  our  subject,  the  more  recently  introduced 
new  local  anaesthetics. 

Oil  of  Eucalyptus. 

This  agent  is  recommended  as  a  local  anaesthetic  in  dental 
operations  and  toothache.  Apply  one  drop  or  more  on  cotton 
to  the  sensitive  dentine  just  before  excavating  for  filling.* 

E  titer  as  a  Local  Ansestlietic. 


Plate  3. 


The  appara- 
tus, Plate  3, 
is  employed  for 
local  anaesthe- 
sia, and  pro- 
duces so  much 
cold  by  atom- 
izing ether  that 
it  freezes  the 
skin,  and  even 
the  deeper  tis- 
sues. It  was  first 
used  by  Dr.  B. 
W.  Richardson, 
of  London,  or 
with  rhigolene 
as  described  by  Dr.  H.  J.  Bigelow,  of  Boston,  or  with  gasoline  as 

*  The  oil  has  also  decided  antiperiodic  powers,  as  well  as  being  one  of  the  best 
stimulating  expectorants,  in  acute,  and  chronic  bronchitis.  From  one-half  to  one 
drachm  a  day  may  be  given  in  divided  doses,  in  capsules  or  mucilage. 


92  ARTIFICIAL   ANAESTHESIA. 

employed  in  Philadelphia.  It  consists  of  the  elastic  bulb  D, 
which,  with  its  valves,  serve  to  force  air  into  the  elastic  chamber 
C,  which,  alternately  expanding  and  contracting,  supplies  a 
steady  stream  of  air  to  the  atomizing  tubes  A,  which  are  of  metal, 
one  branch  of  which  dips  into  the  bottle  B,  containing  the  ether, 
and  the  inner  tube  for  delivering  the  ether  runs  upwards  to  the 
extremity  of  the  outer  tube.  The  ether  must  be  directed  on  the 
surface,  and  must  be  the  strongest,  therefore  free  from  alcohol 
and  water.  AVhen  the  parts  are  properly  frozen  they  become  pale, 
shrunken  and  tallowy-looking,  and  when  cut,  like  frozen  fat. 

When  the  rubber  bag  D  is  compressed  by  the  hand,  the 
reservoir  bulb  is  filled,  and  a  double  current  of  air  is  produced ; 
one  current  descending  and  pressing  upon  the  ether,  forcing  it 
along  the  inner  tube,  and  the  other  ascending  through  the  outer 
tube,  and  playing  upon  the  column  of  ether  as  it  passes  from 
the  inner  tube.  The  ether  which  is  used  in  England  for  pro- 
ducing local  anaesthesia  is  a  mixture  of  amyl  hydrate  and  an- 
hydrous ether;  it  has  a  low  boiling-point  and  specific  gravity, 
and  is  dangerous  when  inhaled.  The  best  form  of  ether  to 
employ  for  local  anesthesia  is  Dr.  Squibb's  anhydrous,  which 
is  almost  free  from  alcohol  and  water,  and  gives  the  best  results. 

liocal  Anaisthetics. — Rhigolene  in  Spray. 

RHIGOLENE.^-This  is  one  of  the  most  volatile  of  liquids, 
and  is  obtained  by  the  distillation  of  petroleum.  Its  specific 
gravity  is  0.625,  and  it  will  boil  in  the  hand.  It  was  first  in- 
troduced by  Dr.  Bigelow,  of  Boston. 

A  superficial  layer  of  the  skin  has  been  successfully  frozen  by 
rhigolene  without  injury.  Not  only  on  theskin,  but  Dr.  Jarvis  and 
others  have  used  it  in  inter-nasal  surgery  by  means  of  an  atomiz- 
ing apparatus,  which  will  freeze  the  tissues  in  less  than  one  min- 
ute. Cartilage  and  mucous  membrane  can,  when  thus  frozen, 
be  deeply  and  freely  divided  without  much  pain  or  hemorrhage. 

Drs.  Edes,  Dana  and  Jacobi  had  used  rhigolene  spray  with 
benefit  in  the  treatment  of  neuralgia ;  but  it  had  been  found  ob- 
jectionable, because  of  the  intense  degree  of  cold  produced,  and 
also  because  it  could  not  be  applied  to  a  sufiiciently  large  space.* 

*  New  Yorlc  Medical  Journal,  July  31,  1887. 


CHLORIDE   OF   METHYL.  93 

In  cases  requiring  extensive  operative  interference,  cocaine 
has  been  partially  utilized  in  conjunction  with  the  rhigolene. 

At  one  time  rhigolene  was  considered  very  explosive ;  this  is 
not  the  case  unless  mixed  with  air,  and  brought  near  to  an 
open  light,  or  the  incandescent  cautery. 

Dr.  Richardson,  of  London,  has  found  rhigolene  to  dissolve 

camphor  and  spermaceti,  which  solution,  applied  with  cotton 

and  wool,  he  found  an  excellent  dressing  to  burns.     This  same 

fluid  would  also  dissolve  iodine,  and  was  valuable  in  diseases 

of  the  respiratory  tract  by  inhalation.     The  strength  of  the 

iodine  solution  which  he  uses,  is  five  grains  to  a  fluid  ounce  of 

rhigolene. 

Methyl. 

This  is  another  new  local  antesthetic,  so  stated,  but  obtained 
from  an  old  agent,  namely,  methyl  alcohol.  This  is  the  alco- 
hol obtained  from  wood  spirit,  and  much  employed  in  Eng- 
land, but  not  in  this  country.  The  new  agent  is  stated  to  be 
neutral,  volatile,  with  an  ethereal  odor  and  pungent  taste. 

The  subcutaneous  injection  of  methyl,  induces  more  or  less 
ansesthesia,  but  it  is  of  short  duration.  (  Vratch,  No.  X.,  1887, 
Bull.  Gen.  de  Tkerap.  July  15,  1887,  and  Amtr.  J.  Med.  Sci. 
October,  1887,  p.  527.) 

Chloride  of  Methyl. 

Dr.  Jacobi  has  found  the  chloride  of  methyl  an  analgesic  or 
local  anaesthetic,  which  did  not  afiect  the  general  condition  of 
the  patient,  and  that  it  was  invaluable  in  the  treatment  of 
neuralgia,  for  the  immediate  relief  of  severe  pain.  It  was 
used  in  the  form  of  spray  under  high  pressure.  The  objection 
was  the  expense  of  the  apparatus,  and  the  difliculties  of  get- 
ting the  drug  (pure). 

(  See  Med.  &  Surg.  Reporter,  vol.  Ivii.,  July  2,  '78,  our  ob- 
servations on  this  drug,  and  its  analogy  to  chloroform  as  usu- 
ally obtained.) 

From  his  experience  in  the  use  of  condensed  carbolic  acid, 
his  conclusions  were,  that  in  the  absence  of  chloride  of  methyl, 
it  was  able  to  take  the  place  of  that  remedy  in  sciatica. 

Drumine  was  discovered  in  Australia,  but  as  yet  has  not,  in 


94  AETIFICIAL  ANESTHESIA. 

the  hands  of  the  profession,  realized  it3  superiority  to  cocaine, 
and  in  a  recent  chemical  examination  of  it  nothing  was  found 
but  a  salt  of  lime. 

Hydrastis  Cauadensis  (Golden    Seal)  and   Hydras- 
tine. 

The  white  alkaloid  contained  in  Hydrastis  canadensis  (Gol- 
den Seal).  Experiment  shows  that  it  is  to  this  alkaloid,  rather 
than  its  more  obtrusive  neighbor,  berberine  (yellow  alkaloid), 
that  the  valuable  properties  of  Golden  Seal  are  due.  Its 
physiological  action,  as  determined  by  experiment  on  the 
lower  animals  is  briefly,  As  follows  : 

"  In  small  doses  it  elevates  and  in  large  doses  depresses  the 
blood  pressure ;  that  in  small  doses  it  produces  contraction,  and  in 
large  doses  dilation  of  the  vascular  walls ;  that  in  the  period  of 
elevated  blood  pressure,  it  inhibits  cardiac  action ;  that  in  small 
doses  it  produces  anemia,  and  in  large  doses  hyperasmia  of  the 
alimentary  surface  ;  that  it  induces  uterine  contractions  ;  that  it  en- 
hances the  irritability  of  the  motor  and  depresses  that  of  the  sensory 
nerves  ;  and  tliat  it  exercises  its  control  over  all  these  organs  through 
a  central,  and  not  through  a  peripheral  influence." 

Experiments  on  man  confirm  the  preceding.  It  dilates 
slightly  the  pupil  of  the  eye,  and  as  a  local  an£Esthetic  has 
value,  though  its  action  is  not  so  marked  as  that  of  cocaine  or 
brucine  applied  locally,  or  theine  injected  hypodermically. 
Hydrastine  is  mostapplicable  in  catarrhal  states  of  the  stom- 
ach, bowels,  eye,  ear,  nose  and  throat,  though  it  is  indicated  in 
many  other  diseased  conditions.  Amongst  the  diseases  for 
which  it  has  been  found  a  valuable  topical  application,  may  be 
mentioned  hyperidosis,  seborrhoea,  acne,  eczema,  ulcers, 
gonorrhoea,  certain  forms  of  gleet,  various  forms  of  conjunc- 
tivitis, and  in  the  ear  to  arrest  or  modify  irritating  catarrhal 
and  purulent  discharges.  Its  effect  of  contracting  the  uterus 
so  powerfully,  may  be  of  special  value  in  obstetrics,  and 
its  marked  action  on  the  spinal  nervous  system  indicates 
it  as  a  valuable  tonic  to  this  portion  of  the  body.  Probably 
hydrastine  possesses  much  of  the  therapy  internally,  as  well  as 
externally,  of  the  drug  from  which  it  is  obtained,  such  as  be- 


CHLOROHYDRATE   OF   EPHEDRINE.  95 

ing  indicated  in  dyspepsia,  constipation,  hemorrhoids,  jaun- 
dice and  other  functional  disorders  of  the  liver,  etc. 

Dose,  xV  to  4  grain. 

Mr.  I.  N.  Bredin  found  the  following  formula,  used  as  an 
injection  4  times  daily,  gives  beneficial  results  in  gonorrhoea, 
and  leucorrhcBa,  when  every  other  treatment,  local  and  internal, 
failed  : 

R      Hydrastin gi. 

Sol.  morphiae  (B.  P.) ^ii. 

Mucil.  acacifB,  ad      f^^^^*     ^^^ 

Sia. — Use  as  an  injection  4  times  daily. 

Care  should  be  taken  to  distinguish  the  resinoid  of  the 
eclectics,  hydrastin,  which  consists  chiefly  of  hydrochiorate  of 
berberine,  from  the  crystalline  alkaloid  hydrastine  (hydras- 
tina). 

Homatropiiie. 

Discovered  by  Ladenburg.  It  is  a  derivative  of  tropeine, 
which  latter  is  produced  by  heating  tropine  gently,  in  contact 
with  organic  acids,  and  dilute  hydrochloric  acid.  Tropine  is  a 
derivative  of  hyoscyamine,  also  of  atropine.  Merck  has  suc- 
ceeded in  crystallizing  it  in  transparent  colorless  prisms.  The 
most  useful  salt  has  been  shown  to  be  the  hydrobromate, 
which  is  crystallizable  and  not  hygroscopic.  Its  action  is 
similar  to  that  of  atropine,  being  mydriatic,  narcotic,  sedative 
and  anaesthetic.  The  dilatation  of  the  pupil  takes  place  very 
energetically  with  homatropine,  the  action  beginning  in  from 
fifteen  to  twenty  minutes,  and  reaching  its  height  after  from 
sixty  to  seventy  minutes ;  while  the  recovery  takes  place  in  a 
comparatively  short  time,  usually  from  six  to  ten  hours.  It  is 
generally  indicated  in  the  same  complications,  as  atropine,  and 
other  alkaloids  of  this  class. 

Chloroliydrate  of  Ephedrine. 

Tweedy  and  Einger  have  proved  by  experimentation,  that 
homatropine  acts  upon  the  heart  in  the  same  way  as  atropia, 
but  is  much  milder  and  safer.  Dr.  Frommuler  prefers  homa- 
tropine to  atropine,  for  checking  the  night  sweats  of  phthisis. 


96  ARTIFICIAL  ANESTHESIA. 

He  also  found  it  an  immediate  and  certain  antidote  to  pilocar- 
pin.     Dose,  i  to  J  of  a  grain. 

Homatropine  has  been  employed  in  a  large  number  of  cases 
in  this  city,  of  the  strength  of  eight  grains  to  the  ounce  of 
distilled  water,  with  the  y-s^-os  of  bichloride  of  mercury. 
The  instillations  have  been  made  every  hour  until  full  dilata- 
tion takes  place,  and  with  satisfactory  result-,  passing  away 
soon,  unless,  as  will  sometimes  happen,  the  druggist  substitutes 
atropine,  not  having  the  homatropine  on  hand. 

The  chlorohydrate  of  ephedrine  is  a  new  mydriatic  alkaloid 
obtained  from  Ephedra  vulgaris  by  M.  Kinnossuke  Menra.  It 
should  be  employed  in  a  solution  ten  times  more  concentrated 
than  homatropine,  but  it  is  much  less  costly.  It  does  not 
paralyze  the  accommodation  for  near  version. 

Hydrobromate  of  Homatropine. 

(CigH^iNOgHB.    Soluble  in  10  parts  of  water.) 
A  careful  study  of  the  action  of  hydrobromate  of  homa- 
tropine by  Risley  and  Jackson,  has  proved  to  them,  that  this 
drug  is  entirely  satisfactory  for  the  correction  of  anomalies  of 
refraction,  and  is  an  efficient  and  reliable  mydriatic. 

Briicine. 

Dr.  Mays,  of  this  city,  introduced  pure  brucine  as  a  local 
ansesthetic,  and  kindly  furnished  us  with  a  solution  in  oleic 
acid.  We  made  a  number  of  careful  experiments  with  it,  and 
found  it  had  some  slight  ansesthetic  properties,  but  with  the 
objection  that  when  used  freely  on  a  mucous  membrane  or 
abraded  surface,  it  produced  some  of  the  symptoms  of  strychnia 
poisoning.  It  is  true,  it  is  less  powerful,  and  eliminated  more 
rapidly  than  strychnia,  but  it  has  one  serious  objection. 
The  old  idea  was,  that  the  effect  of  brucine,  in  producing 
convulsions,  was  said  to  depend  on  admixture  with  strychnia, 
but  Dr.  L.  Brunton  found  that  pure  brucine  would  produce 
convulsions  and  death  in  rabbits  when  injected  subcutaneously. 

Lewinin  is  an  alkaloid,  allied  to  cocaine,  but  much  inferior 
to  it. 


ERYTHROPHLEINE,    OR    HAYA.  97 

Apomorpliiae  Hydrocliloras. 

The  objection  to  apomorphia  h  that  it  causes  very  profuse 
secretions  from  the  mucous  membranes.  It  also  acts  as  a 
poison  on  tlie  muscular  fibre  of  the  ventricle  of  the  heart,  like 
an  acid  when  employed  internally.  Yet  there  are  ophthalmic 
surgeons  of  this  city  who  use  it  with  success,  applying  it 
every  ten  or  fi^fteen  minutes  to  the  eye,  one  drop  at  a  time. 

Erytliroplileine,  or  Haya. 

(The  active  principle  of  Erythrophloium  Guinecnse.) 
Fromamostinterestingpaper,  read  a  month  ago  (January  11th, 
1888),  before  the  Medical  Society  of  Berlin,  by  Dr.  L.  Lewein,  we 
extract  the  following,  concerning  a  drug  that  promises  much : 

"The  hydrochloride  of  erythrophleine  (made  by  E.  Merck, 
of  Darmstadt)  is  readily  soluble  in  water.  A  two  per  cent. 
solution  in  a  dog's  eye,  renders  it  insensible  for  from  10  to  24 
hours.  This  solution  is  micc/i  stronger  than  need  be  for  anses- 
thetic  uses,  as  will  be  seen  as  we  proceed;  for  Dr.  Lewein 
states  that  '  solutions  of  the  strength  of  one-fourth  or  one-tenth 
or  one-twentieth  of  one  per  cent,  produce  anaesthesia  of  the 
cornea  and  conjunctiva,  continuing  for  from  several  hours  up 
to  two  days,  and  gradually  decreasing  in  intensity  during  that 
time.'  The  action  is  altogether  local,  and  if  a  solution  of  it  be 
injected  into  the  erjelid  of  an  animal,  it  becomes  so  insensible 
that  touch  does  not  induce  motion,  while  the  eye  itself  retains 
perfectly  its  sensibility. 

"  To  give  an  idea  of  the  powerful  action  of  this  substance. 
If  we  make  a  solution  of  the  proportion  of  xV  gramme  to  100 
grammes  of  water,  i.  e.,  xV  gramme  to  2000  drops  of  water 
(approximately  f  of  a  grain  to  one  fluid  ounce  or  a  solution  of 
about  xfir  of  one  per  cent.),  and  of  this  inject  three  full  drops 
into  the  eye,  full  anaesthesia  is  produced  (by  0.00015  grammes 
erythrophleine  hydrochloride)  (or  twenty-three  ten-thous- 
andths of  a  grain).  If  from  0.0005  grammes  to  0.0015  grammes 
of  this  solution  be  injected  into  a  guinea-pig,  such  an  insensi- 
bility is  produced  in  the  injected  part,  that  one  can  cut  these 
otherwise  so  sensitive  animals  deeply,  down  to  the  muscles, 
without  observing  any  symptom  of  pain." 
5 


98  ARTIFICIAL   ANJESTHESIA. 

According  to  "  Karewski,"  Iledical  Press,  March  4,  1888, 
complete  antcsthesia  was  never  obtained,  but  its  action  was 
much  heightened  by  the  local  production  of  anaemia.  Its 
action  was  not  uniform  in  all  cases.  Subcutaneous  injection 
of  at  least  Jj  of  a  grain  was  necessary  to  produce  analgesia. 

The  after-effects  were  very  disagreeable,  amongst  them 
violent  pain  at  the  point  of  insertion,  coming  on  in  a  few 
minutes  afterwards,  and  becoming  intolerable,  lasting  several 
days. 

Caflfema—  Caffeine. 

A  crystalline  principle  occurring  in  tea  and  coffee.  Various 
trials  of  caffeine  have  not  been  satisfactory  as  a  powerful  local 
anaesthetic.  It  is  valuable  in  slight  operations,  but  much  in- 
ferior to  cocaine. 

Theine,  which  chemically  is  the  same  as  caffeine,  has  also 

slight  anaesthetic  properties.     They  are  both  most  valuable 

diuretics. 

Hellel>orine. 

The  Hellehorus  niger  contains  two  active  principles,  helle- 
borine  and  helleborin.  Both  of  the  substances  are  glucosides. 
The  first  has  been  employed  as  a  local  anaesthetic.  Internally 
they  are  both  narcotics  and  active  cardiac  poisons. 

Canadol. 

This  is  a  volatile  product  obtained  from  naphtha.  Liquid, 
limpid,  very  volatile,  easily  inflammable,  benzoine  odor.  It 
has  been  used  as  a  substitute  for  ether  as  a  local  anaesthetic, 
and  is  employed  by  means  of  Richardson's  spray  apparatus. 

Menthol.* 

Has  been  found  useful  as  a  rubefacient,  like  mustard,  but 
unless  combined  with  some  hypnotic,  it  has  but  slight  anaes- 
thetic properties.    It  is  useful  combined  with  cocaine. 

Iodoform.     (CHI,,  392-8.) 
Iodoform  is  employed  as  a  local  anaesthetic  and  antiseptic, 
as  a  dressing  after  operations.    Preparation  :  Mix  an  alcoholic 

*  Menthol,  or  oil  of  peppermint  camphor,  is  employed  in  diseaaes  of  tho  throat  and 
ear  ;  dissolved  in  ether,  or  olive  oil,  from  10  to  50  per  cent. 


IODOFORM   AS   A   LOCAL   ANESTHETIC.  99 

solution  of  potash  with  tincture  of  iodine,  and  evaporate  it. 
Character :  Small,  lemon-yellow,  lustrous  crystals  of  the  hex- 
agonal system,  having  a  saffron-like  and  disagreeable  odor, 
very  difficult  to  overcome,  and  unpleasant  iodine-like  taste. 
Not  perceptibly  soluble  in  water,  soluble  in  eighty  parts  of 
alcohol  at  59'^  F.,  in  6  parts  of  ether,  and  in  chloroform,  benzol, 
benzine,  and  in  the  fixed  and  volatile  oils,  lard,  lanoline  or 
vaseline.     Dose,  1.-3  grains. 

It  is  given  in  the  form  of  a  pill  or  in  a  capsule,  or  mixed 
with  tragacanth,  sugar  of  milk  and  glycerine,  or  better,  sugar- 
coated  ;  by  the  rectum  in  the  form  of  a  suppository  or  vaginal 
capsule.  The  disagreeable  smell  may  be  in  part  covered  by 
Tonquin  bean,  coumarin,  or  roasted  coffee  in  powder. 

As  an  inhalation  in  phthisis  a  solution  maybe  used  contain- 
ing 20  grains  of  iodoform,  20  minims  of  oil  of  eucalyptus,  or 
10  of  creasote,  ^  fl.  oz.  rectified  spirit,  and  J  fl.  oz.  ether.  This 
is  used  with  an  inhaler  of  horse-hair  matting,  lined  with  cotton 
wool,  on  the  interior  of  which  the  solution  is  dropped. 
(Dreschfeld.) 

As  an  external  application,  it  is  dusted  over  the  abraded 
skin,  ulcer  or  mucous  membrane.  An  old  favorite  preparation 
for  topical  application,  is  the  ethereal  solution  of  iodoform 
(si  i V-)  applied  with  absorbent  cotton  to  the  affected  parts  in 
the  nares,  post-pharyngeal  space,  mouth,  fauces,  larynx  and 
trachea.  The  nozzle  of  the  spray  producer  is  apt  to  become 
choked  and  must  be  washed  out  frequently  with  pure  ether. 
It  may  also  be  applied  to  the  nose  in  the  form  of  a  bougie,  con- 
taining I  to  i  grain  made  with  gelatine  and  glycerine. 

Actions  :  Iodoform  destroys  bacilli,  and  is  an  antiseptic 
deodorizer  and  local  anaesthetic.  It  also  destroys  leucocytes. 
If  given  in  large  doses  it  weakens  the  circulation,  or  if  long 
continued  in  moderate  doses,  it  has  the  same  action.  If 
absorbed  from  a  large  raw  surface  or  employed  too  freely,  it 
produces  muscular  rigidity,  ansesthesia,  sleep  followed  by 
sleeplessness,  headache,  irritability,  hallucinations,  loss  of 
memory,  melancholia  and  even  death.  These  disagreeable 
effects  are  diminished  by  bicarbonate  of  potash,  10-grain  doses 
every  hour  or  two,  in  water. 


100  ARTIFICIAL  ANJ3STHESIA. 

It  has  a  most  extraordinary  power  to  prevent  the  develop- 
ment of  giant  cells,  and  may  thus  prevent  the  growth  of  morbid 
tissue,  as  cancer,  etc.  After  death  from  iodoform  the  heart, 
liver,  kidneys  and  muscles  exhibit  fatty  degeneration. 

Iodoform.  (Cotton  Wick.) 
Gersung,  of  Vienna,  has  found  cotton  wick  impregnated  with 
iodoform  an  excellent  material  for  tampons  in  the  drainage  of 
wounds  whose  secretion  is  moderate ;  Bellroth's  clinic  wick, 
saturated  with  tannin  and  iodoform,  is  used  with  excellent 
results.  Its  removal  is  much  less  painful  and  inconvenient 
than  that  of  gauze.     ( Centralblatt  fur  Chirurgie,  July  30,  '87.) 

Deodorized  Iodoform  and  Ointment. 

Mr.  Louis  Genois,  has  advocated  the  use  of  the  purified 
naphthaline  to  mask  the  odor  of  the  iodoform,  as  follows  : 

Purified  naphthaline 7^  grains. 

Powdered  turmeric li  grains. 

Iodoform 91    grains. 

Rub  together  until  thoroughly  mixed.    ■ 

Ointment  Iodoform. 

Deodorized  iodoform  (as  above) gii. 

Oil  of  almond ,    gss. 

Lanoline      5  vss.  M. 

We  have  tried  this  preparation,  but  the  strong  odor  of  the 
naphthaline  is  one  objection. 

Iodoform  in  Variola. 

Cnlleville  has  had  excellent  results  in  preventing  severe 
scarring,  and  lessening  pain  in  variola  by  the  local  use  of : 

Iodoform 1  part. 

Vaseline 20  parts. 

Although  used  freely  in  cases  of  confluent  variola,  no  ill 
effects  were  observed. — Revue  de  Therapeutic,  Nov.  5,  1889. 

Iodoform  Deodorized. 

Cantrella,   pharmacist,   Paris,   has   found   of  all   the  ways 


lODOrOEM.  101 

devised  for  hiding  the  odor  of  iodoform,  the  following  com- 
bination is  the  best : 

Iodoform gr.  xv. 

Menthol gr.  !• 

Essence  of  lavender  (of  best  quality) gtt.  1. 

In  addition,  the  hands  may  be  washed  in  water  containing 
a  little  lavender  brandy  or  essence.  Cocaine  may  be  added  to 
the  mixture,  when  instant  anaesthesia  is  required,  as  follows : 

Iodoform gr.  xv. 

Cocaine gi'-  f  • 

— Bulletin  General  de  Therapeutic,  Nov.  15,  1887. 

For  deodorization  of  hands  or  any  other  part  of  the  body  im- 
pregnated with  iodoform,  Doux,  in  the  Bulletin  of  the  Pharma- 
ceutical Society  of  Bordeaux,  advises,  first,  vigorous  soaping  of 
the  hands,  then  washing  them  in  water  to  which  is  added  tincture 
of  iris  (blue  or  white  flag),  when  the  odor  disappears  completely. 

Increasing-  tlie  Antiseptic  Powers  of  Iodoform. 

G.  de  Ruyter  {Arch.  f.  Kl.  Ghirurg.  Bd.  xxxv.,  Hft.  1)  states 
that  solutions  of  iodoform  in  ether  and  alcohol  have  greater 
antiseptic  properties  than  the  powdered  drug,  owing  to  the 
production  of  free  iodine.  The  following  solution  was  found 
an  excellent  antiseptic,  and  much  superior  to  the  ethereal  one : 

Iodoform 1  part. 

Ether 2  parts. 

Alcohol 8  parts. 

The  author  confesses  that  outside  of  the  body  iodoform  has 
little  power  over  the  greater  number  of  disease  germs.  It  has, 
however,  been  shown  that  when  in  contact  with  the  fluids  of 
the  body  the  iodoform  is  decomposed,  and  is  then  capable  of 
acting  on  bacteria. 

An  Antidote  for  Iodoform. 

The  Rep.  de  Farms  states,  that  Dr.  Behring  recently  gave  a 
twenty  per  cent,  solution  of  bicarbonate  of  potassium,  in  a  case 
of  severe  iodoform  poisoning.  The  best  results  followed  its 
use,  it  seeming  to  act  as  a  direct  antidote  to  iodoform.     For- 


102  ARTIFICIAL   ANAESTHESIA. 

tunately,  cases   of  iodoform  poisoning  are  rare;   so  much  so 
indeed,  that  they  are  termed  "  idiosyncrasies." 

Treatment  of  Diarrhoea  toy  Iodoform  and  Charcoal. 

B      Iodoform grs.  9. 

Ether 38^ 

Vegetable  charcoal,    finely    powdered     ...     ^3^ 
Glycerin |12. 

The  iodoform  must  be  dissolved  in  the  ether,  and  the  pow- 
dered charcoal  thoroughly  mixed.  After  the  ether  has  evap- 
orated, the  glycerine  should  be  added.  It  is  given  in  tea- 
spoonful  or  tablespoonful  doses,  suspended  in  a  glass  of  water. 

On  the  Local  Use  of  Iodoform  in  Ear  Diseases 
and  Dental  Operations. 

The  following  were  the  conclusions  of  our  friend,  the  late 
Dr.  Cassell,  after  using  this  agent  in  the  treatment  of  ear 
diseases  for  some  years. 

"  Iodoform  is  of  service  alone  in  cases  of  ear  disease,  in 
which  there  is  a  lesion  of  tissue  (ulceration),  and  notably  in 
those  of  caries  of  the  mastoid,  complicated  with  polypus 
granulations.  After  these  are  removed  the  local  application 
of  iodoform,  as  a  fine,  dry  powder,  generally  acts  capitally, 
and,  I  may  add,  successfully.  I  intend,  however,  to  give  it  a 
trial  as  an  internal  remedy,  not  with  much  hope  of  success, 
resulting,  I  confess,  in  those  cases  of  deafness  following  eye 
disease,  having  keratitis  and  scooped  (Hutchinson's)  teeth, 
and  other  outward  signs  of  hereditary  syphilis. 

"Nerve  Paste. — A  preparation  for  devitalizing  dental  pulps, 
composed  as  follows :  R  Iodoform  pulv.,  cocaine  hydrochlo- 
rat.  aa  gr.  xx ;  menthol  crust.,  gr.  v ;  glycerina,  q.s.  to  make  a 
stiff  paste. 

"  Iodoform  has  not  been  much  used  by  the  dental  practitioner, 
but  I  think  in  it  we  have  a  remedy  that  exactly  meets  the 
requirements  of  some  cases.  It  possesses  the  alterative  prop- 
erties of  iodine,  without  its  caustic  qualities ;  indeed,  it  is  a 
very  soothing  application  to  inflamed  and  irritated  parts. 
It  has  been  used  with  the  happiest  result   in  the  treatment 


IODOFORM,  103 

of  old  abscesses,  its  alterative  and  anodyne  qualities  ren- 
dering it  just  the  thing  for  those  cases  in  which,  from  the 
ravages  of  calculus  or  from  abscess,  the  socket  cells  are  in- 
volved, and  that  peculiarly  annoying  neuralgia  results,  from 
which,  the  patient  finds  slow  relief.  In  these  cases  even  the 
extraction  of  the  tooth  does  not  always  bring  the  immunity 
sought  for  some  time. 

"To  apply  the  paste,  take  a  probe  armed  with  cotton,  and 
take  up  some  of  the  compound  paste,  introduce  it  into  the 
cavity,  or  under  the  gum  and  around  the  roots. 

"  It  can  be  introduced  into  the  crown  and  roots,  to  relieve 
neuralgia,  or  to  cure  persistent  abscess.  In  the  treatment  of 
antral  disease,  it  is  regarded  as  one  of  the  very  best  remedies. 
Used  as  above  directed,  its  effect  is  very  soothing,  and  it  will 
speedily  diffuse  itself,  and  its  influence,  over  the  seat  of  irri- 
tation. If  some  persons  should  object  to  the  odor,  the  iodol 
may  be  substituted  in  the  place  of  the  iodoform." 

Iodoform  Gauze  Tampons. 

Iodoform  gauze  tampons  have  been  found  useful  in  rectal 
disease.  They  are  stated  to  be  painless  and  antiseptic.  The  mode 
of  preparation  of  the  iodoform  gauze  is  given  by  Dr.  Weir, 
as  follows  ("  Antiseptics :  How  Used,  and  How  Made,"  Med. 
News,  Dec.  17,  '87)  : 
Pour  over  5   yards  of  absorbent  gauze,  a  mixture  of 

Iodoform giiiss. 

Resin      §iss. 

Alcohol g  iv. 

Glycerin ^vi.      M, 

The  Anti-Bacterial  Action  of  Iodoform. 

In  a  recent  article  by  I.  Amory  Jeffries,  M.D.,  of  Boston 
[Amer.  J.  Med.  Sci.,  January,  1887),  he  states  that  iodol  and 
salol  gave  prompt  results  of  anti-bacterial  action,  but  iodoform, 
he  concludes,  from  numerous  experiments,  has  no  direct  action 
as  a  germicide,  a  result  agreeing  with  Heyn  and  Roosing. 
Looked  at  from  the  clinical  side,  the  ultimate  object  of  all  med- 
ical research,  he  gives  the  following  rules  : 


104  ARTIFICIAL  ANiESTHESIA. 

1.  Iodoform,  not  being  a  germicide,  ia  not  a  fit  substance  to 
use  to  procure  asepsis  of  instruments,  materials  or  wounds. 

2.  Iodoform  is  allowable  in  the  present  state  of  our  pharma- 
copoeia, in  inflicted  wounds  where  the  true  germicides  are  con- 
tra-indicated, as  by  danger  of  poisoning  or  impracticability. 

3.  As  has  long  been  known,  iodoform  has  a  decided  tendency 
to  stop  serous  oozing,  and  therefore  may  be  indicated  in 
wounds  whei'e  the  moisture  threatens  the  integrity  of  the  asep- 
tic or  antiseptic  dressing.  Laboratory  tests  are  not  always 
what  occurs  in  the  body,  and  diiferent  observers  produce  differ- 
ent results.  Dr.  Robert  T.  Weir,  of  New  York,  with  his  friend. 
Dr.  Weeks,  has  published  in  Med.  News,  Dec.  17,  '87,  the  fol- 
lowing observations  on  antiseptics  :  Iodoform  in  powder  only 
retarded  development  of  germs  after  twelve  hours'  exposure, 
lodol  in  powder  exerted  no  effect.  Whoever  has  kept  abreast 
with  the  current  literature,  will  not  be  surprised  at  two 
things :  First,  that  the  fact  taught  us  several  years  ago  by  Kock, 
has  been  confirmed  by  Dr.  Weeks,  that  only  solutions  or  mix- 
tures of  the  various  antiseptics  have  no  value  other  than  is 
slowly  exerted  by  the  fatty  matters  themselves;  and,  second, 
that  iodoform — concerning  the  power  of  which  in  germs  much 
has  lately  been  written — exerts  its  germicide  action  but  slowly. 
On  this  point  of  the  value  of  iodoform  in  controlling  inflam- 
mation— ordinary  and  tuberculous — Dr.  Weir  says,  that  the. 
clinical  experience  of  surgeons  is  in  favor  of  its  usefulness,  and 
is  decidedly  opposed  to  the  laboratory  deductions.  The  discus- 
sion of  this  subject,  however,  has  developed  the  fact  that  this 
substance,  in  dry  powder,  often  contains  germs,  and  that  it  works 
best  when  acted  upon  and  changed  by  wound  secretions. 
Practically,  it  is  nearly  always  used  in  a  dampened  condition, 
by  him,  in  the  New  York  Hospital,  in  conjunction  with  the 
moist  sublimate  gauze.  In  this  combination  it  is  depended  upon 
as  a  supporter  of  antiseptics. 

lodol. 

"lodol,  (CINH)  is  produced  by  the  action  of  iodine  on  pyrol 
in  the  presence  of  caustic  potash.  It  has  an  acid  reaction,  is 
free  from  the  disagreeable  odor  of  iodoform,  and  contains  88.9 


lODOL.  10~J 

per  cent,  of  iodine.  It  is  a  yellowish  brown  powder,  insoluble 
in  water,  slightly  soluble  in  cold  alcohol,  and  readily  soluble  in 
oil.  According  to  Mazzoni,  it  is  a  more  powerful  antiseptic 
than  iodoform  ;  it  acts  as  a  local  anaesthetic  and  favors  granula- 
tion ;  administered  internally  in  doses  of  two  grains,  it  produces 
no  intestinal  disturbance.  It  may  be  used  in  the  same  way  as 
iodoform. 

"  I  have  been  using  this  agent  in  the  place  of  iodoform.  Very 
many  of  my  patients  object  to  the  odor  of  iodoform ;  iodol,  being 
odorless,  has  this  great  advantage,  though  its  cost  at  present  is 
much  greater  than  that  of  the  iodoform,  I  have  found  it  as 
useful  as  iodoform  in  ear  and  throat  affections.  It  has  been 
stated  that  it  is  not  so  valuable  in  intra-uterine  affections  as 
iodoform. 

"  Dr.  Assaky,  of  Bucharest,  Roumania,  said  that  wounds  unite 
under  iodol  by  first  intention.  This  union,  however,  being  the 
result  of  various  and  complex  conditions  attending  operation, 
it  is  not  possible  to  attribute  to  iodol  alone  the  absence  of  sup- 
puration and  inflammatory  conditions.  In  wounds  which  gape 
and  suppurate,  iodol  is  an  excellent  antiseptic.  It  rapidly  re- 
tards suppuration,  renders  it  inodorous,  reduces  the  frequency  of 
dressing,  and  hastens  considerably  cicatrization.  In  ulcerating, 
or  gangrenous  wounds,  iodol  aids  to  resist  the  destructive  pro- 
cess, and  changes  the  wound,  after  a  variable  time,  to  a  healthy 
granulating  condition.  This  action  of  iodol  extends  itself  to 
hard  chancres.  In  case  of  soft  chancres  the  result  is  variable. 
Sometimes  it  transforms  them  into  a  simple  wound  with  brief 
delay ;  at  others  it  is  insufficient  for  this  purpose,  and  it  be- 
comes necessary  to  employ  in  addition,  locally,  antiseptic  lo- 
tions. The  same  is  true  with  reference  to  open  venereal  buboes 
of  the  groin."  The  powdered  iodol  has  this  advantage  over 
iodoform,  that  it  is  free  from  odor  and  is  not  toxic  in  its  effect. 

"  Doses  of  iodol  of  from  one-sixteenth  of  a  grain  to  three 
grains  daily  produce  no  functional  trouble,  even  if  continued 
a  long  time.  These  doses  give  marvelous  results  in  tertiary 
syphilis  and  in  scrofulous  affections.  In  the  secondary  stage 
of  syphilis,  taken  internally,  it  rapidly  destroys  the  syphilitic 
manifestations.     Iodol  seems  to  aid  the  general  nutrition  and 

6* 


106  ARTIFICIAL   ANiESTHESIA. 

increase  strength  and  flesh.  It  is  indicated  in  all  oases  of  spe- 
cific malnutrition.  lodol  is  an  antipyretic.  In  acute  infec- 
tious diseases,  such  as  erysipelas,  etc.,  it  causes  a  rapid  fuli  of 
temperature. 

"  (1)  Powder  of  Iodol. — The  pure  powder  may  be  used;  it 
is  readily  dusted  over  a  raw  surface,  or  insufflated  into  the 
throat.  Possessing  no  toxic  power,  it  is  of  more  importance  to 
cover  the  diseased  surface  than  to  measure  the  dose.  For  all 
laryngeal,  pharyngeal,  post-uasal  and  oral  conditions,  this 
is,  perhaps,  the  most  generally  useful  application. 

"  (2)  A  Solution  in  Alcohol  and  Glycerine. — This  was 
Mazzoni's  original  application:  lodol,  one  part;  alcohol,  six- 
teen parts ;  glycerine,  thirty-four  parts.  This  forms  a  good 
application  by  means  of  the  brush,  or  may  be  used  as  a  very 
coarse  spray. 

"  (3)  Iodol,  one  drachm  ;  Ether,  one  ounce. — This  forms 
a  clear  brown  solution,  useful  for  application  either  by  the  spray 
or  brush.  The  ether  quickly  evaporating,  leaves  the  powder 
ill  situ.     It  is  useful  for  naso-pharyngeal  atrophic  conditions. 

"  (4)  Iodol,  one  drachm  ;  Glycerine,  one  drachm  ;  Vas- 
eline, seven  drachms. — This  is  a  modification  of  one  of 
Rumboid's  sprays.  It  is  a  very  soothing  application  for  pha- 
ryngeal conditions.     It  requires  to  be  warm  before  using. 

"  (5)  Iodol  Pastilles. — Iodol,  one  grain  ;  glycerine,  one 
minim  ;  glycogelatine,  eighteen  grains.  These  are  very  useful 
for  chronic  pharyngeal  conditions,  and  are  much  preferable  to 
iodoform  pastilles. 

"(6)  Iodol  Bougies,  containing  half  grain  of  iodol  in  each. 
These  are  made  for  me,  for  use  in  diseased  nasal  conditions. 

"(7)  Iodol  Wool,  ten  per  cent.,  for  tampons,  etc. 

"(8)  Iodol  Gauze  for  dressings. 

"  I  have  used  iodol  in  a  number  of  cases  of  laryngeal  phthisis, 
with  very  beneficial  results.  Adopting  Lubliuski's  method,  I 
have  applied  it  as  an  insufflation  of  the  pure  powder,  in  some 
cases  once  daily,  in  others  three  times  a  week. 

"  Ulcerations  in  the  inter-arytenoid  region  have  cleansed  and 
healed  up  completely,  and  the  characteristic  arytenoid  oedema 
has  diminished  under  its  influence.     Tuberculous  ulcerations 


lODOL.  107 

of  the  epiglottis  and  pharynx,  have  been  benefited  by  it  and 
been  arrested,  and  the  distressing  pains  on  deglutition  which 
accompany  this  condition  are  much  relieved  by  iodol.  In  some 
patients,  to  whom  solid  food  was  entirely  interdicted  by  reason 
of  the  pain  on  swallowing,  deglutition  has  become  compara- 
tively easy,  under  daily  laryngeal  insufflations  of  iodol.  If  the 
iodol  is  carefully  and  accurately  applied  over  the  ulcerations,  it 
will  completely  heal  them.  I  have  cases  under  treatment 
where  there  was  originally  extensive  laryngeal  ulceration, 
but  at  present  all  active  mischief  is  arrested.  Iodol  remark- 
ably diminishes  the  cough  of  this  condition.  It  is  not  to  be  sup- 
posed, of  course,  that  insufflations  of  iodol,  or  of  any  other  sub- 
stance, will  cure  extensive  phthisical  disease  of  the  larynx,  but 
they  will  certainly  arrest  ulceration,  relieve  pain  and  cough, 
and  allow  the  patient  comparative  comfort.  The  iodol  remains 
for  a  long  time  in  contact  with  an  ulcerated  surface.  Sprays 
of  chloride  of  zinc  (gr.  xxx  ad  5  1)  have,  in  some  cases,  been 
combined  with  the  iodol  treatment.  For  ozaena,  I  find  that  iodol 
tampons  are  eflfective  in  arresting  the  foul  smell  of  nasal  caries, 
or  for  the  true  ozseuic  conditions  independent  of  carious  bone. 

"  As  a  spray  or  brush  application  it  is  very  beneficial  for  naso- 
pharyngeal atrophic  catarrhs.  For  the  ordinary  forms  of  pha- 
ryngitis, accompanied  or  not  with  follicular  disease,  I  find  it  a 
very  serviceable  insufflation,  and  one  which,  moreover,  is  not 
unpleasant  to  the  patient.  The  pastilles  are  also  grateful  in 
these  conditions.  It  is  important  that  the  application  of  iodol, 
as  of  any  other  medicament,  to  the  nasal,  pharyngeal  or  la- 
ryngeal mucous  membrane,  should  be  preceded  by  thorough 
cleansing  of  these  parts  with  the  alkaline  lotion,  so  as  to  insure 
the  bringing  of  the  powder  into  direct  contact  with  the  dis- 
eased tissue,  and  not  merely  to  lay  it  on  the  surface  of  the  mu- 
cus. I  have  found  it  produce  excellent  effect  in  extensive  ul- 
cerations of  the  inside  of  the  cheek,  dusted  over  the  exposed 
surface  twice  daily.  In  cases  where  there  is  great  pain,  the 
addition  of  one-eighth  to  one-quarter  grain  morphine  to  the 
iodol  insufflated  will  be  found  very  advantageous. 

"  To  summarize :  iodol  is  odorless  or  nearly  so,  tasteless,  pro- 
duces no  constitutional  effects,  contains  nearly  as  much  iodine 


108  ARTIFICIAL  ANiESTHESIA. 

as  iodoform,  and  parts  with  it  more  readily  ;  it  is  antiseptic, 
anaesthetic,  a  promoter  of  granulation  and  healing;  arrests 
suppuration,  and  deodorizes  foul  secretions.  Possessing  thus 
all  the  virtues  of  iodoform,  it  is  surely  preferable  on  account  of 
its  pleasant  and  slight  odor  and  the  absence  of  taste.  It  does 
not  disturb  the  stomach  as  iodoform  does." — R.  Norris  Wolfen- 
den,  M.D.,  in  the  Practitioner. 

Iodoform  and  lodol. 

Is  iodol  perfectly  safe  given  internally  and  employed  locally? 
The  experiments  of  Marcus  and  Pahl  {Maug.  Dess.  Berlin, 
Ther.  Gazette,  January  16,  1888)  show  that  when  iodol  was 
given  in  sufficient  doses  to  animals,  it  caused  emaciation, 
albuminous  urine,  fall  of  temperature,  general  loss  of  muscular 
power,  and  finally  death  from  fatty  degeneration  of  the  liver, 
.kidney  and  other  tissues.  In  a  case  published  in  the  Ther. 
Gazette  (see  Vol.  XI.,  p.  768),  iodol  caused,  when  used  as  a 
surgical  dressing,  symptoms  of  poisoning.  Still  it  is  less 
poisonous  than  iodoform,  but  the  post-mortem  appearances  are 
the  same.  It  has  been  found  valuable  in  a  number  of  cases  of 
tubercular  laryngitis,  throwing  the  pure  powder  into  the  larynx 
once  a  week ;  also  in  ozsena  with  good  results,  alone  or  com- 
bined with  creasote  and  glycerine  and  boracic  acid. 

Iodol  in  Diphtheria. 

In  order  to  test  the  statements  of  Dr.  Mazzoni,  Dr.  L.  L. 
Stembo,  of  Vilna,  tried  ("Proceedings  of  the  Vilna  Medical 
Society,"  No.  V.,  1887,  p.  114)  the  local  use  of  iodol  in  seven 
cases  of  diphtheria,  two  of  which  were  severe.  The  drug  was 
applied  either  alone,  in  powder,  or  in  the  form  of  a  solution. 
(R  lodoli.  9ss;  liq.  vini  ^s^;  glycerine,  ^iiis?.)  All  the 
patients  recovered  after  treatment  lasting  from  four  to  six  days. 
The  advantages  claimed  by  Dr.  Stembo  for  iodol,  are  its  com- 
plete harmlessness,  its  freedom  from  unpleasant  smell  or  taste, 
the  painlessness  of  its  application,  and  the  absence  of  any 
untoward  or  secondary  effects,  such  as  loss  of  appetite,  nausea, 
vomiting,  etc. — British  M-idical  Journal,  April  9,  1888. 

Trousseau  has  found  the  following  formula  useful: 


BROMIDE   OF    ETHYL.  109 

For  an  ointment: 

Vaselin ?i  '^i- 

lodol gr.  30  to  60. 

In  solution : 

lodol 8  parts. 

Alcohol 35  parts. 

Glycerine 62  parts. 

In  disease  of  the  ducts,  as  tiie  lachrymal,  etc.,  the  following 
was  found  useful : 

Liquid  vaseline Z  '^i' 

lodol gr.  45. 

[Revue  Gen.de  Clin.et  TVier.,  December  29, 1887 ;  Med.  News, 
January  28,  1888). 

Mazzoni,  who  first  proposed  the  use  of  iodol  in  practical 
medicine,  employed  a  solution  composed  of  iodol,  one  part; 
alcohol,  sixteen  parts ;  and  glycerine,  thirty-four  parts. 

The  dose  of  iodol  is  from  two  to  three  grains  a  day,  but  both 
Pick  and  Assaky  have  given  as  high  as  thirty  grains  a  day, 
without  injury.  Pick  asserts  that  iodol  is  absorbed  much  less 
freely  than  iodoform,  requiring  from  twelve  to  eighteen  hours 
for  the  full  elimination  of  the  iodine  in  the  urine,  when  tested 
by  a  solution  of  starch. 

Dr.  Harlan,  of  Chicago,  uses  iodol  in  combination  with  pure 
terebene,  as  a  topical  application  to  lacerated  edges  of  the 
gums,  after  the  removal  of  necrosed  bone.  It  has  been  also 
found  beneficial  in  the  treatment  of  pyorrhoea  alveolus.  Com- 
bined with  oleum  gaultherise,  it  forms  an  excellent  antiseptic 
in  destroying  the  odors  in  the  cavities  of  diseased  teeth,  and 
controlling  pain. 

Bromide  of  Ethyl  as  a  Local  Ansesthetic. 

The  bromide  of  ethyl  has  advantages  as  a  local  anaesthetic, 
a  pleasant  odor,  not  inflammable,  and  has  been  used  in  France 
and  this  country  with  good  results.  The  ordinary  atomizer 
produces  a  satisfactory  spray  with  the  bromide  of  ethyl,  ether 
and  rhigolene. 


110  ARTIFICIAL   ANAESTHESIA. 

Bromide  of  Potassium  as  a  Local  Auajsthetic  for 
the  Urinary  and  Sexual  Apparatus. 

Bromide  of  potassium  has  long  been  used  as  a  local  appli- 
cation to  the  throat  and  larynx  to  diminish  sensibility.  Acting 
upon  this  suggestion,  J.  Kijanizyer  (St.  Petersburg  Med. 
Wochenschr.,  No.  51,  1879 — Medical  Record)  applies  it  in  a 
similar  manner,  and  with  similar  eflfects  to  the  genito-urinary 
apparatus.  He  injects  a  solution  of  salt  into  the  urethra, 
when  the  latter  is  the  seat  of  painful,  acute  or  chronic  inflam- 
mation in  strictures,  and  in  cases  of  frequent  pollutions.  In 
urethritis,  he  says,  that  the  pain,  redness  and  tumefaction  of 
the  mucous  membrane  decreased  rapidly,  the  discharge  dimin- 
ished, and  soon  disappeared  entirely  with  the  aid  of  mild 
astringents.  In  a  case  of  stricture,  with  chronic  urethritis  and 
painful  micturition,  where  the  urethra  was  extremely  sensitive, 
and  the  severe  pain  prevented  the  introduction  of  bougies,  in 
spite  of  the  use  of  cannabis  indica  and  belladonna  salve,  a 
bougie  was  introduced  with  scarcely  any  pain  after  the  use  of 
bromide  of  potassium  injections  for  seven  days.  Kijanizyer 
uses  eight  grammes  of  potassium  bromide  dissolved  in  180 
grammes  of  water.  Four  grammes  of  the  fluid  are  injected  two 
or  three  times  a  day,  and  the  fluid  retained  in  the  urethra  a 
few  minutes.  From  his  observations  he  concludes  that  the 
injections  are  of  decided  use  in  all  cases  where  the  indication 
is  to  diminish  sensibility  in  the  urethra  and  neck  of  the 
bladder;  in  the  treatment  of  strictures  with  bougies,  in  inflam- 
mations of  the  urethra  and  their  complications ;  in  chordee, 
dysuria,  neurosis,  etc.,  and  for  pollutions  depending  upon  peri- 
pheral causes.  He  also  recommends  the  local  use  of  the  salt, 
as  indicated  in  catarrh  of  the  bladder  and  of  its  neck,  in 
increased  sensibility  of  the  latter,  and  for  cystic  calculi  and 
the  like.  He  considers  the  effects  to  be  due  to  the  diminished 
irritation  and  lessened  quantity  of  blood  in  the  inflamed  tissue. 

Ethyl  Iodide. 

This  agent  has  been  found  useful  as  a  local  ana3stbetic,  and 
anti-spasmodic  in  hay  fever,  and  cold  in  the  head.  It  is  most 
effiectively  applied  by   means  of  glass  capsules  broken  in  a 


CHLORAL    AND    CAMPHOR.  Ill 

handkerchief,  and  then  inhaled  from  it,  covering  the  face. 
Another  method  is  by  means  of  a  half-filled  glass  bottle,  -which 
8  enclosed  in  the  hand,  the  heat  vaporizing  the  liquid. 

Chloral  and  Camplior  as  a  Local  Anaesthetic. 

Equal  parts  of  chloral  and  camphor  were  recommended 
years  ago  by  Dr.  Fordyce  Barker,  to  stop  the  secretion  of 
milk,  and  now  we  note  from  the  Canada  Med.  and  Surg.  Jour., 
March,  1885,  that  before  the  Medico-Chirurgical  Society  of 
Montreal,  Dr.  Lapthorn  Smith  read  a  paper,  on  the  use  of  a 
mixture  of  about  equal  parts  of  chloral  hydrate  and  camphor, 
as  a  local  ansesthetic.  He  stated  that  when  placed  in  the 
solid  form  together  in  a  bottle  they  soon  produced  a  clear, 
thick  liquid,  which,  when  applied  on  a  piece  of  lint,  covered 
with  oil-silk,  to  a  painful  surface,  complete  analgesia  resulted. 
He  reported  three  cases  in  which  he  tried  it  with  good  suc- 
cess. The  first  was  a  whitlow  of  the  finger,  which  the  patient 
refused  to  have  opened.  Shortly  after  applying  it  the  pain 
disappeared,  and  three  days  later  it  was  lanced,  and  the  pus 
let  out  without  the  patient,  a  young  lady,  experiencing  any 
pain  whatever.  The  second  case  was  a  very  painful  bubo, 
which  completely  disabled  the  patient,  a  gentleman,  from 
doing  his  work.  The  mixture  of  chloral  hydrate  and  camphor 
was  applied  frequently  on  a  piece  of  lint,  with  the  result  that 
a  few  hours  after  the  first  application  he  was  so  much  relieved 
that  he  returned  to  his  duties  next  day,  and  fluctuation  be- 
coming evident  a  few  days  later,  it  was  opened,  the  operation 
causing  only  about  a  quarter  of  the  usual  amount  of  pain. 
The  third  case  was  an  operation,  for  the  removal  of  a  large 
sebaceous  cyst  of  the  face,  which  was  accomplished  after  the 
frequent  application  of  the  local  anaesthetic  for  several  hours 
previously  by  means  of  a  brush.  The  incision  in  the  skin  was 
almost  painless,  but  it  produced  no  effect  upon  the  deeper 
structures,  to  which  the  cyst  was  firmly  adherent.  The  action 
of  the  anaesthetic  is  much  less  marked  on  healthy  than  on  in- 
flamed and  painful  skin. 


112  ARTIFICIAL    ANAESTHESIA. 

Piper  Methysticuni,  and  the  Cocaine  Molecule. 

Filelm  remarks  {Berl.  Klin.  Woch.,  vii.,  1887),  that  for  a 
time  cocaine  seemed  to  stand  alone  in  its  local  anaesthetic  ac- 
tion. Then  a  similar  property  was  found  to  belong  to  the 
resin,  from  Plpsr  mefhysflcum  (Kava).  All  the  ordinary  alka- 
loids have  been  tested  in  reference  to  this  point  by  Bergmees- 
ter  and  E.  Ludwig,  with  negative  results.  Searching  after  a 
substitute,  Filehn  directed  his  attention  to  the  chemical  con- 
stitution of  the  cocaine  molecule.  Just  as  atropine  can  be 
split  up  into,  and  reconstituted  from,  tropic  and  acid  tropin, 
so  cocaine  into  benzoic  acid  and  ecgonine. 

IS^aphtlialin. 

Naphthalin  (Cio  Hs)  is  the  product  of  the  distillation  of 
coal  tar,  of  which  it  possesses  the  disagreeable  odor.  It 
should  be  carefully  used  on  account  of  its  irritant  effects  on 
the  renal  tissues,  and  the  peculiar  modifications  in  the  nutri- 
tion of  the  eye. 

Carbolic  Acid. 

Carbolic  Acid  [carbo,  and  oleum,  "oil"). — Carbolic  acid, 
impure  {aciduni  carbolicum),  a  liquid  obtained  from  coal  tar 
oil,  by  treating  it  first  with  an  alkali,  then  with  an  acid, 
and  finally  distilling  it.  It  is  of  a  brownish  shade,  becoming 
reddish  brown  on  exposure.  It  consists  of  carbolic  acid  and 
cresylic  acid,  with  impurities  derived  from  the  coal  tar. 

This  form  is  only  used  externally,  or  for  disinfecting  pur- 
poses, and  at  the  iron  works  mixed  with  oil  for  relieving 
burns. 

PuBE  Carbolic  Acid  {Acidum  carbolicum  purificatum), — 
When  pure,  and  while  it  is  in  crystals  or  liquid,  it  is  also 
termed  phenic  acid,  or  phenol.  Its  odor  and  taste  is  like 
creaaote,  fusible  at  from  93  to  104,  forming  an  oily  liquid, 
soluble  in  from  20  to  33  parts  of  water,  and  in  alcohol 
ether,  glycerine  and  the  essential  oils.  Carbolic  acid,  if  ap- 
plied to  the  skin,  produces  pain  and  local  ana3sthesia,  so 
that  the  actual  cautery  and  other  irritating  substances  can  be 
applied,  or  incision   made  with   comparative   impunity.     In 


CAEBOLIC   ACID,  113 

the  form  of  slightly  carbplized  oil,  it  is  most  valuable  in 
burns  over  a  large  area  of  skin,  yet  care  must  be  observed 
for  fear  of  absorption,  if  there  is  much  loss  of  the  skin. 
It  is  also  used  in  treating  surgical  diseases  by  hypodermic 
injections,  as  hydrocele  and  hemorrhoids.  Carbolic  acid 
prevents  or  corrects  putrefaction  in  cases  of  purulent  infection, 
dissecting  wounds,  hospital  gangrene,  and  parasitical  diseases 
of  the  skin,  as  scabies,  prurigo,  thrush.  Internally  it  may  be 
given  in  doses  of  from  ^  to  2  grains,  in  a  tablespoon ful 
of  some  bland  liquid  every  hour,  in  cases  of  yeasty  vomiting, 
flatulence,  dependent  on  fermentation  in  undigested  food.  Its 
salts,  as  the  carbolate  of  soda,  of  potash,  zinc,  have  been  used 
externally  for  local  application  and  for  disinfecting  purposes  ; 
also  in  various  aqueous,  alcoholic  and  ethereal  solutions,  and 
in  the  form  of  liniment  and  ointments. 

It  has  been  ascertained  that  if  animals,  to  whom  carbolic 
acid  had  been  previously  administered,  are  treated  by  sodi  sul- 
phate, a  harmless  compound  of  phenol  and  sulphuric  acid  is 
formed.  Thus  it  has  been  found  that  the  symptoms  of  car- 
bolic acid  poisoning  are  relieved  by  the  free  use  of  this  agent. 
If  this,  or  even  the  common  Glauber  salt  is  given  when  the 
urine  becomes  dark-colored,  it  will  arrest  the  toxic  phenomena 
from  slow  poisoning.  In  these  sudden  cases,  when  the  carbolic 
acid  is  swallowed  in  such  large  quantities,  it  has  been  advised 
to  resort  to  zinci  sulphate,  sulphate  of  magnesia,  Epsom 
salts,  or  any  sulphate.  After  the  evacuation  of  the  stom- 
ach, the  free  use  of  lime  water,  and  olive  or  linseed  oil  is  use- 
ful, to  soothe  the  burnt  mucous  membrane,  and  when  this  is 
not  at  hand,  resort  to  flour  starch,  eggs  or  milk  with  warm 
water.  While  a  resident  physician  at  the  Philadelphia  Hos- 
pital, a  fatal  case  of  poisoning  took  place  from  swallowing  the 
ordinary  liquid  acid,  which  is  of  a  brown  color,  resembling 
brandy ;  the  individual  mistaking  it  for  that  agent,  swal- 
lowed it,  and  collapse  followed,  death  was  almost  imme- 
diate. Several  similar  cases  have  occurred  since.  The  seventh 
case  occurred  at  Liverpool  quite  recently,  the  acid  being  mis- 
taken for  spirits,  reported  in  a  Glasgow  paper  while  we  were 
on  a  visit  to  that  city.     In  the  case  which  we  first  had  the 


114  ARTIFICIAL  ANJ5:STHESIA. 

opportunity  of  seeing  there  was  a  post-mortem  made,  and  the 
whole  tissue,  from  the  throat  to  the  rectum,  was  of  a  brown 
color,  and  changed  to  a  leather-like  consistency,  while  the 
urine  and  other  secretions  were  black. 

Carbolic  acid  has  produced  poisoning  both  by  its  local  appli- 
cation and  by  its  being  swallowed.  Children  and  delicate 
women  have  been  the  sufferers  by  its  free  local  application.  It 
produces  a  species  of  intoxication.  The  symptoms  are,  in  the 
case  of  adults,  nausea,  vomiting  and  headache;  but  in  children 
the  symptoms  are  more  severe,  the  temperature  falling  below 
normal,  the  pulse  being  extremely  weak,  and  the  body  covered 
with  a  cold  sweat. 

Death  from  Carbolic  Acid. — At  Milton,  Ohio,  on  October 
6th,  a  three-year  old  child  secured  a  bottle  of  carbolic  acid  and 
a  teaspoon,  and  began  feeding  it  to  the  baby  brother  in  the 
cradle.  The  screams  of  the  baby  attracted  the  mother,  who 
was  outside,  and  when  she  reached  its  side  it  was  gasping  for 
breath,  and  died  in  a  few  minutes. — The  Journal  of  the  Am, 
Med.  Association,  October  13,  1888. 

Fatality  in  a  Belfast  Hospital. — A  patient  in  Belfast 
Hospital,  named  James  Jeffers,  was  accidentally  poisoued  in 
that  institution,  through  taking  a  draught  of  carbolic  acid, 
which  the  nurse  of  the  ward  in  which  he  was  located,  gave 
him  in  mistake  for  a  black  draught.  After  drinking  a  por- 
tion of  the  stuff,  Jeffers  remarked,  "  You  have  given  me  the 
wrong  medicine,''  and  fell  back  insensible.  The  nurse  having 
discovered  the  mistake  by  testing  the  liquid,  rushed  wildly 
for  the  house  physician,  who  was  promptly  in  attendance. 
Antidotes  were  administered,  but  the  man  died  an  hour 
afterwards.  Miss  Torrens,  who  was  taken  seriously  ill  shortly 
after  tasting  the  poison,  was  placed  under  arrest.  She  was 
not  aware  of  the  death  of  the  patient,  and  the  doctors  con- 
sidered it  would  be  injudicious  to  inform  her  of  the  fact.  The 
affair  created  quite  a  sensation  in  Belfast,  where  Miss  Torrens' 
friends  move  in  the  best  society. 

Another. — Another  death  from  carbolic  acid  poisoning — 
the  eighth  in  a  few  weeks — occurred  at  Liverpool,  a  woman 
drinking  the  poison  in  mistake,  as  usual,  for  spirits. 


ANTIPYRIN   AS   AN   ANESTHETIC.  115 

Quinine,  Antipyrin  and  Antifetorin  are  Antipyi*etic 
and  Anaesthetic. 

The  first  and  best  known  of  the  agents  is  the  active  principle 
of  cinchona,  or  quinia,  and  its  various  salts,  but  chiefly  the 
sulphate,  which  is  now  so  extensively  employed.  This  valua- 
ble medical  agent,  some  twenty  years  ago,  was  most  employed 
by  Fenner,  of  New  Orleans, and  in  enormous  doses  as  a  sedative 
in  all  kinds  of  fever ;  but  it  was  found  that  in  many  instances  it 
depressed  the  nervous  system  and  acted  most  injuriously  upon 
the  patient — so  that  at  the  present  day  it  is  no  longer  em- 
ployed in  such  poisonous  doses.  Soon  after,  the  Germans  took 
up  this  same  drug,  and  described  it  as  an  antipyretic,  and  with 
it  endeavored  to  reduce  the  temperature  of  all  fevers,  especially 
that  of  typhoid  fever.  In  thus  endeavoring  to  cure  the  disease 
by  the  simple  reduction  of  temperature,  they  did  not  effect  a 
cure,  but  frequently  the  immense  doses  of  quinine  acted  as  a 
poison  upon  the  nervous  system  as  an  anaesthetic,  and  caused 
the  death  of  the  patient. 

At  the  present  day  it  is  resorted  to  chiefly  as  an  antiseptic 
to  combat  or  destroy  the  various  forms  of  bacteria,  or  micro- 
cocci, and  diseases  of  a  remittent  or  intermittent  type.  To 
obviate  its  injurious  effects  upon  the  nervous  system,  it  is  com- 
bined with  the  bromide  or  hydrobromic  acid,  or  extract  of 

ergot. 

Antipyrin. 

Another  new  and  important  agent  which  has  been  intro- 
duced as  a  temperature  reducer,  is  the  antipyrin,  which  is 
termed  an  analgesic  febrifuge  and  haemostatic : 

CeHsN/CO-CH 
\__N0 

CU3— CIT3 

Antipyrin  is  a  febrifuge,  lowering  the  temperature  for  about 
five  or  six  hours.  By  many  it  is  preferred  to  quinine  in 
typhoid ;  but  care  should  be  employed,  else  its  depressing 
effects  act  injuriously;  and  it  is  well  to  give  with  it  small 
quantities  of  alcohol  or  wine.  It  is  not  so  useful  as  quinine  in 
intermittent  fever.  The  dose  is  five  grains,  repeated  every 
hour,  in  a  compressed  pill  or  tabloid.     This  is  the  quantity 


116  ARTIFICIAL   ANiESTHESIA. 

usually  required  in  cases  of  pain  pyrexia,  until  fifteen  grains 
are  given  ;  then  it  is  well  to  omit  it  for  a  time.  The  drug  is  free 
from  the  tinnitus  auriura  of  quinine,  and  its  peculiar  action  on 
the  brain ;  but  acts  injuriously  if  too  long  continued  as  a  car- 
diac depressant,  and  will  cause  death  in  delicate  individuals  by 
anaesthesia  of  the  nervous  system.  In  children  with  diph- 
"theria,  it  is  not  to  be  recommended,  and  should  not  be  em- 
ployed in  large  doses,  not  more  than  a  half-grain  dose,  if 
the  child  is  five  years  old.  It  may  be  given  hourly  until  pain 
is  relieved  and  fever  lowered. 

It  is  a  valuable  agent  in  erysipelas,  and  relieves  the  pain  in 
sub-acute  rheumatism  and  dysmenorrhcea.  If  it  occasions 
nausea  by  the  mouth,  it  may  be  given  hypodermically,  or  in 
enemata.  Five  grains  is  considered  by  us  as  equal  to  one-third 
of  a  grain  of  sulphate  of  morphia.  It  has  been  given  with 
excellent  results  in  migraine,  facial  neuralgia,  lumbago,  sciatica, 
biliary  and  renal  colic,  administered  in  five-grain  doses  every 
half-hour,  until  fifteen  grains  are  taken,  or  relief  obtained  ;  or, 
it  may  with  advantage  be  combined  with  a  pill  of  two  grains 
each  of  quinine  and  one-sixth  of  a  grain  of  the  hydrochlorate 
of  cocaine.  It  has  been  found  useful  by  us  in  certain  forms  of 
bronchial  catarrh,  of  a  rheumatic  origin ;  also  in  whooping- 
cough,  asthma,  dyspnoea  of  bronchitis,  and  pains  of  locomotor 
ataxia.  In  severe  attacks  of  migraine,  from  ten  to  fifteen 
grain  doses  are  given  every  twenty  minutes  or  half-hour,  and 
three  doses  taken  consecutively  almost  always  remove  the  pain. 
A  single  dose,  if  given  durina:  the  premonitory  signs,  will  ward 
off  an  attack.  Antipyrin,  when  given  to  certain  young  females 
for  migraine,  sometimes  produces  dyspnoea,  with  blueness  of 
the  lips  and  skin;  and  in  other  cases  a  species  of  intoxication  ; 
BO  that  it  is  well  to  be  on  one's  guard.  It  should  be  given 
mixed  with  sugar  or  gumarabic,  as  it  is  of  a  disagreeable  taste, 
or  may  be  dissolved  in  water,  wine  or  lemonade.  An  eruption 
sometimes  occurs  from  its  use.  The  antifebrin  has  much  the 
same  composition,  and  has  very  analogous  action  as  that  of 
antipyrin,  and  is  used  in  the  same  doses  and  requires  the  same 
caution  in  its  use. 


ANTIPYRIN   IN   DYSMENOERIICEA.  117 

Antipyrin  as  an  Anaesthetic. 

Guerel  {UArt  Medical)  has  given  subcutaneous  injections 
of  twenty-five  centigrammes  of  antipyrin  to  twenty  patients. 
Fifteen  out  of  the  twenty  had  perfect  anaesthesia,  and  felt  a 
remarkable  diminution  of  pain  while  in  labor,  nor  did  it  in- 
terfere in  any  way  with  its  normal  course. 

Local  Anaesthetic  Action  of  Antipyrin. 

Hypodermic  injection  of  antipyrin  has  been  strongly  rec- 
ommended for  the  relief  of  pain  by  "See"  and  others.  "See" 
considers  that  it  rivals  morphine  in  the  extent  of  its  action, 
that  it  has  not  the  unpleasant  after-effects  of  that  drug,  and 
that  it  does  not  interfere  with  nutrition  or  lead  to  a  "craving."' 
Berdach  has  lately  been  experimenting  with  the  drug  in  this 
way  at  Professor  Bamberger's  clinic  at  Vienna.  He  uses  a 
fifty  per  cent,  solution  in  distilled  water,  and  has  experienced 
nothing  but  favorable  results.  All  kinds  of  painful  conditions 
were  so  treated,  the  injection  being  made  at  the  most  painful 
spot.  For  a  few  seconds  after  administration  there  is  a  local 
pain  and  burning,  but  this  soon  passes  off,  and  is  followed  by 
analgesia  over  an  area  of  more  than  a  centimetre  round  the 
point  of  injection.  Frankel,  and  others,  had  previously  noticed 
this.  The  most  important  point  in  Berdach's  observations  is, 
that  the  pain  is  relieved  in  a  few  seconds  after  the  injection, 
the  relief  lasting  for  at  least  six  hours.  No  disagreeable  effects, 
such  as  vomiting,  sweating,  rash  on  the  skin,  or  depression  of 
the  heart  or  pulse  were  noticed,  and  in  those  patients  who 
were  febrile  the  temperature  remained  uninfluenced.  This  is 
too  favorable  an  account,  and  we  cannot  endorse  these  state- 
ments and  would  advise  caution  in  its  use.* 

Antipyrin  in  Dysmenorrlioea. 

In  five-grain  doses  it  will  relieve  the  pain  of  dysmenorrhoea 
and  wearing  pains  during  the  first  stage  of  labor.  It  some- 
times checks  the  menstrual  flow,  and  produces  headache  dur- 
ing the  first  two  or  three  days.  In  almost  all  cases  in  which 
antipyrin  or  antifebrin  are  employed,  a  little  wine  is  added  to 
counteract  the  depressing  influence  upon  the  heart. 

*It  is  also  valuable  in  chronic  catarrh  in  the  form  of  spray,  dissolved  in  hot  water 
from  10  to  40  grains  to  the  ounce. 


PART    SECOND. 

NITROGEN  MONOXIDE-NITBOUS  OXIDE  GAS 

(NO"N,0). 


CHAPTER    XI. 


Nitrous  Oxide  Gas^Mode  of  Preparation  and  Chemical  Composition 
— -Gasometer  and  Inhaling  from  it — Liquid  Nitrous  Oxide  and 
Inhalei'S — Aasesthesia  from  Nitrous  Oxide — Physiological  Action 
of  Nitrous  Oxide  Gas — Experiments  with  the  Gas — Additional 
Facts  in  Reference  to  the  Physiological  Action  of  Nitrous  Oxide. 


^^ 


Nitrous  Oxide  Gas,  its  Mode  of  Preparation  and 
Chemical  Composition. 

Nitrogen  monoxide,  or  nitrous  gas  (NO — N„0)is  prepared  from 
the  nitrate  of  ammonia,  (this  is  now  obtained  from  the  waste 
product  of  gas  works  by  the  action  of  nitric  acid  and  is  then 
purified),  which  resolves  itself  into  the  gas  and  water,  thus ; — 

NO3NH,  ==  O  =  NjO  +  2  H2O. 

The  nitrate  of  ammonia  is  a  crystalline  salt,  but  for  con- 
venience of  introduction  into  the  retorts  should  be  in  a  granu- 
lated form,  which  can  be  obtained  of  the  manufacturing 
chemist,  or  of  The  S.  S.  White  Dental  Manufacturing  Co., 
Philadelphia,  New  York,  Boston,  Chicago  and  Brooklyn. 

Gasometer  for  Preparing-  Nitrons  Oxide  Gas. 

The  second  important  matter  is  to  be  furnished  with  a  con- 
venient gasometer,  an  illustration  of  which,  is  seen  at  Plate  5, 
with  Nos.  1,  2  and  3,  and  these  can  be  obtained  from  the  dental 
118 


GASOMETEE   FOE   NITEOUS   OXIDE   GAS. 


119 


depots.  Care  is  required  in  the  selection  of  the  bottles  for  wash- 
ing and  purifying  the  gas.  Plate  4,  represents  a  very  good  form, 
which  is  furnished  with  perforated  rubber  cork,  and  glass  tubes, 
bent  at  right  angles.  The  long  tube  is  pierced  with  small  holes 
at  the  bottom,  to  compel  the  breaking  up  of  gas,  and  so  insure  its 

/more  thorough  washing.  In  purifying  the  gas  some  employ  a, 
solution  of  sulphate  of  iron  in  one  bottle,  and  pure  water  in  the 
other  two.  To  remove  chlorine  gas,  which  is  sometimes  present, 
and  can  be  noticed  by  its  green  color,  and  irritating  vapor 
upon  the  respiration,  a  small  stick  of  caustic  potash  is  added 
to  one  of  the  bottles  containing  the  water.  When  no  chemical 
agents  are  employed  in  the  purification  of  the  gas,  it  should  be 
well  washed  through  fresh  water,  and  allowed  to  stand  for  // 
^  some  hours  over  the  water  in  the  gasometer,  to  remove  SlUJ  // 
impurities  that  may  have  passed  over.  Plate  5,  represents  the 
gasometer  in  position.  The  holder  is  first  filled  with  water,  to 
within  one  and  a  half  or  two  inches  of  the  top ;  while  this  is 
being  done,  take  off  the  weights  and  open  all  the  spigots,  to 
allow  the  air  to  pass  out,  and  the  receiver  to  remain  in  position. 


Plate  4. 


The  long  pipe  of  bottle  No.  1,  must  not  dip 
under  the  water,  for  the  tubing  thereby  be- 
comes choked  with  dense  vapor,  and  the 
free  passage  of  air  is  interrupted. 

Into  wash-bottle  No.  2,  place  about  four 
ounces  of  sulphate  of  iron,  and  add  sufficient 
water  to  cover  the  end  of  the  dip-pipe,  about 
oiie  and  a  half  to  two  inches. 

Into  the  wash-bottle  No.  3,  it  is  unneces- 
sary to  place  anything  but  fresh  water; 
yet  some,  fearing  the  chlorine,  add  a  stick 
of  caustic  potash.  Sufficient  water  should 
be  employed  to  cause  the  pipe,  which  dips 
into  the  water,  to  sink  the  same  depth  as  it 
does  in  No.  2. 

When  bottles  are  prepared,  connect  them 
with  a  piece  of  rubber  tubing,  and  to  the 
spigot  of  the  gasometer.  If  they  are  arranged  properly  a  cur- 
rent of  air  blown  into  the  tube,  intended  to  connect  with  the 


riateS— (Figs.  1-3). 


GASOMETER  AND   INHALER. 


120 


/ 


\ 


^ 


GASOMETER    FOR   NITROUS    OXIDE    GAS.  121 

retort,  will  cause  the  water  to  bubble  in  the  wash-bottles  Nos. 
2,  and  3,  and  if  the  spigot  A  is  open,  the  receiver  will  commence 
to  ascend. 

Having  the  bottles  in  readiness,  and  properly  connected, 
place  the  quantity  of  nitrate  of  ammonia  which  will  be  required 
into  the  retort  (one  pound  of  the  granulated  salts  will  produce 
about  thirty  gallons  of  the  gas). 

There  is  a  stove-like  arrangement  heated  by  gas-burners,  with 
a  sand-bath  for  holding  and  heating  the  retort.  Connect  the 
retort  with  the  long  pipe  of  the  first  bottle  by  the  rubber  tubing, 
and  then  open  the  spigot  of  the  gasometer.  . 

The  heat  must  be  applied  gradually,  first  to  melt  the  am-  ^* 
monia,  about  226°  F.,  and  then  to  cause  it  to  boil  and  give  off 
gas  at  460°  F.  to  480°  F.  until  it  is  nearly  all  decomposed. 
When  the  gas  has  ceased  to  come  over,  take  a  cloth  and  dis- 
connect the  retort  from  the  tubing,  and  close  the  spigot  of  the 
gasometer.  ^.-^^ 

The  inhaling-tube  is  attached  to  the  spigot  at  the  top  of  the 
holder.  There  is  a  register  which  shows  the  number  of  gallons 
of  the  gas  in  the  receiver.  When  the  holder  is  filled,  close  the 
spigot  and  arrange  the  weights  ;  it  is  then  ready  to  receive  the 
gas.  The  wash-bottles  are  placed  as  represented  in  Nos.  1,  2,  3, 
which  are  connected  one  with  the  other,  and  to  the  retort  and 
gasometer,  by  means  of  rubber  tubing.  The  first  bottle.  No.  1, 
is  placed  next  to  the  retort,  and  is  simply  used  to  catch  the 
drip  resulting  from  condensed  vapor. 

The  water  and  solutions  contained  in  the  wash-bottles  should 
be  changed  once  in  a  month.^^hen  nitrous  oxide  gas  is^\ 
thus  obtained,  it  is  colorless,  almost  inodorous,  and  of  a  sweetish 
taste.  The  chemical  decomposition  is  as  follows : — nitrate  of 
ammonia  resolves  itself  into  nitrous  oxide  gas  and  water ;  thus 
N03NHt=  NjO  4-  2  HjO.  The  heat  necessary  to  cause  active 
evolution  of  gas  is  stated  to  be  460°  F.,  and  this  heat  should  be 
kept  up,  else  a  portion  of  the  salt  will  sublime.  The  heat 
should  never  be  allowed  to  rise  above  482°  F.,  as  the  nitric  oxide 
is  apt  to  be  given  off  in  the  form  of  an  orange-colored  vapor.>^^ 
n  infinitesimal  explosions,  nitric  oxide  is  a  dangerous  impurity, 
as  it  cannot  be  breathed  unless  very  much  diluted,  and  tends 
6 


122  ARTIFICIAL    AN.ETSIIESIA. 

to  suspend  respiration  and  produce  spasm  of  the  muscles  of 
inspiration.  To  determine  the  proper  temperature,  a  ther- 
mometer is  prepared  which  can  be  passed  into  the  cork,  and 
into  the  retort,  so  that  no  risk  need  be  incurred  by  the  intro- 
duction of  poisonous  materials  into  the  gas. 

After  the  gas  is  made,  it  should  stand  over  water  a  few 
hours,  not  longer,  else  endosmotic  action  will  take  place  and 
weaken  the  gas  before  using.  But  this  Avill  do  little  toward 
insuring  absolute  purity  of  the  gas ;  neither  will  washing  it 
through  solution  of  iron  and  potash  purify  it  perfectly.  Should 
there  be  chlorine  present  (which  is  the  poisonous  element)  in 
the  nitrate  of  ammonia,  no  amount  of  washing  through  solu- 
tions will  obliterate  it^^The  ammonia  should  always  be  tested  ^ 
before  using,  which  is  done  by  dissolving  about  a  teaspoonful 
in  a  half-tumbler  of  distilled  water,  and  applying  a  few  crystals 
of  the  nitrate  of  silver.  If  the  ammonia  be  pure  the  solution 
will  remain  perfectly  clear;  but  should  chlorine  be  present,  it 
will  show  a  clouded  appearance,  and  the  ammonia  must  be  dis-y 
.  "^   carded  altogether. 

Iron  Retorts  for  Making  Protoxide  of  Nitrogen  Gas. 

Nitrous  oxide  for  dental  operations  has  now  come  into 
general  use,  and  dentists  making  their  own  nitrous  oxide, 
must  have  doubtless  met  with  great  difficulties  in  consequence 
of  the  breaking  of  the  glass  retorts-  To  obviate  this  incon- 
venience, the  idea  has  been  suggested  to  use  iron  retorts. 
One  can  be  made  of  rolled  iron,  fourteen  inches  long  by  six 
inches  wide,  outside  measure,  of  a  quarter  of  an  inch  thick, 
the  joints  being  brazed  together  and  perfectly  air-tight.  The 
bottom  of  the  bottle  is  convex  outside  and  concave  inside, 
and  the  top  opening  is  one  inch  wide,  with  a  threaded  screw 
inside  the  mouth  of  the  bottle.  To  this  is  attached  a  tube  two 
feet  long  with  a  threaded  screw,  to  enable  the  unscrewing  of 
the  tube,  in  order  to  put  the  nitrate  of  ammonia  into  the  bottle. 
The  iron  tube  is  bent  at  a  curve  just  above  the  mouth  of  the 
bottle,  and  is  two  feet  long,  and  the  other  end  of  the  tube 
being  on  a  level  with  the  mouth  of  the  bottle,  the  bottle  can 
be  either  suspended  or  placed  over  a  gas-burner,  or  on  a  fire. 


INHALER   FOR  NITROUS  OXIDE.  123 

and  the  receiver  remain  in  position.  Tlie  iron  retort  must  be 
lined  with  porcelain,  and  the  gaa  must  be  purified  before  being 
employed,  by  the  aame  method  as  above  directed. 

Inhalers. 

Next  to  pure  gaa,  a  perfect  inhaler  is  the  most  essential  thing 
to  the  successful  administration  of  nitrous  oxide. 
Plate  6. 


THOMAS'   N1TE.0US   OXIDE   INHALER. 

The  Thomas  Inhaler,  Plate  6,  used  with  gasometer,  is  turned 
from  a  piece  of  vulcanized  rubber,  eight  inches  long  by  three 
inches  square,  leaving  the  mouth-piece  one  inch  and  a  half  across. 
The  diameter  of  the  opening  is  a  little  more  than  one-half  an 
inch,  with  stop-cock  in  the  centre,  in  which  is  the  inhaling  valve, 
being  constructed  of  a  simple  piece  of  rubber  dam  secured 
by  a  pin  to  a  stopple,  in  which  are  three  oblong  apertures,  as 
is  the  inhaling  valve  at  the  extremity  of  the  inhaler.  The 
aperture,  being  of  sufficient  size,  is  made  not  to  obstruct  the 
free  passage  of  the  nitrous  oxide  gas ;  the  valves  are  three- 
quarters  of  an  inch  in  diameter,  and  the  stoppie  is  of  vulcan- 
ized rubber. 

It  must  have  a  tube,  large  enough  to  admit  the  gas  so  freely 
that  the  most  nervous,  as  well  as  patients  with  weak  lungs,  can 
inhale  through  it  without  exertion,  and  it  must  be  perfectly 
air-tight. 

Some  inhalers  are  so  constructed  that  it  is  onlyby  using  great 
effort  that  patients  can  supply  air  to  the  lungs  to  their  natural 
capacity,  causing  them  to  struggle  or  go  into  the  anaesthetic 
sleep  with  such  feelings  of  suffocation  and  depression,  that  they 
will  drift  into  dreaoas  of  the  most  frightful  character,  and  be- 
come almost  unmanageable  in  their  excitement. 


124 


ARTIFICIAL  ANAESTHESIA. 

riate  7— (Figs.  1-2). 


It  is  necessary  that  the  valves 
should  be  perfectly  air-tight,  so  as 
to  administer  the  gas  free  from  any 
atmospheric  air,  onebreath  of  which 
is  suflicient  to  dilute  two  or  three  of 
the  gas ;  and  should  there  be  a  con- 
tinued supply  through  the  valves, 
it  will  require  three  times  the  quan- 
tity of  gas,  and  the  anaesthesia  so 


produced  will  be  of  such  a  nature  as 
not    to    render    the    patient    utterly 
oblivious  to  the  effects  of  the  opera-  ^ 
tion. 

This  inhaler  (Fig.  1)  is  the  clean 
liest,  most  convenient,  and  most  efiec 
tive  ever  used  for  the  administration  of  ( 
nitrous  oxide.  It  is  almost  entirely  au- 
tomatic in  its  action,  and  requires  the 
use  of  but  one  hand, the  inlet  valve  be- 
ing opened  by  a  slight  pressure  of  the 


INHALER  FOR   NITROUS   OXIDE.  125 

thumb,  so  that  the  gas  can  be  turned  on  without  the  patient's 
knowledge.  Upon  the  removal  of  the  pressure,  the  valve  closes 
automatically  and  shuts  oflf  the  gas. 

The  sectional  view  (Fig.  2)  shows  the  internal  construction. 
An  opening,  B,  underneath  the  body  of  theinhaler,  admits  the  gas 
through  a  similar  opening  A,  in  a  sliding  tube  GG,  fitted  inside 
of,  and  projecting  beyond  the  rear  portion  of  the  main  body. 
The  projecting  portion  is  perforated  for  the  admission  of  air, 
and  its  outer  end  is  closed  by  a  cap.  At  the  inner  end  of  the 
sliding  tube,  is  a  coil  spring,  EE,  abutting  against  a  shoulder  in 
the  body  of  the  inhaler.  This  spring  holds  the  sliding  tube  in 
the  position  shown  in  the  cuts,  closing  the  inlet  B,  when  the  gas 
is  not  being  used.  Pressure  on  the  cap  compresses  the  spring, 
closes  the  perforations  for  the  admission  of  air,  and  brings  the 
opening  A,  over  B,  affording  a  free  flow  of  gas  to  the  mouth- 
piece through  the  inhaling  valve.  •  The  sliding  tube  is  prevented 
from  rotating  by  the  screw-pin  D,  which  works  in  a  slot,  C. 
The  inhaling  and  exhaling  valves — the  former  internal,  the 
latter  external — consist  of  two  thin  disks  of  mica,  F  F,  which 
are  inclosed  in  circular  open  cages.  The  inhaling  valve  is 
opened  in  respiration,  by  being  drawn  against  the  front  of  the 
cage,  the  exhaling  valve  being  closed  by  the  pressure  of  the  out- 
side air.  In  expiration,  both  disks  are  thrown  against  the  fur- 
ther ends  of  the  cage,  opening  the  exhaling,  and  closing  the  in- 
haling. 

The  entire  inhaler,  except  the  mouth-piece,  and  the  two 
valve-disks,  is  of  metal,  smoothly  finished,  the  outside  polished 
and  nickel-plated.  It  is  readily  taken  apart  for  cleaning.  The 
illustrations  are  half-size. 

In  this  form  of  face-piece,  the  oval  shape  is  maintained  by 
the  peculiar  metal  fittings,  as  shown  in  detail. 

The  inhalers  which  cover  the  entire  face  are  sometimes  ob- 
jectionable to  delicate  patients.  In  cases  of  gentlemen  with 
beards  it  is  impossible  to  give  the  gas  without  the  admission 
of  air.  It  must  be  remembered  that  the  color  of  the  blood,  as 
shown  through  the  mucous  membrane  of  the  lips,  is  one  of  the 
principal  guides  to  the  condition  of  the  patient,  during  the  inha- 
lation of  gas ;  and  if  they  are  covered  from  view  by  the  hood  or 


126  ARTIFICIAL  ANAESTHESIA. 

otherwise,  we  have  lost  that  means  of  diagnosis.  In  instances 
of  hare-lip,  or  where,  from  swelling  or  other  causes,  the  muscles 
of  the  jaw  become  so  contracted,  as  to  render  it  impossible  to 
pass  the  mouth-piece  between  the  teeth,  a  rubber  covering  is 
recommended. 

Inflatable  Face-piece  for  Inlialer. 

The  Inflatable  Face-piece  consists  of  a  soft  rubber  hood 
with  an  inflatable  edge-cushion,  attached  to  a  metal  frame 
which  is  screwed  into  the  inhaler.  The  frame,  which  preserves 
the  shape  of  the  hood,  may  be  readily  detached  for  cleansing, 
by  unscrewing  the  nut  which  holds  it  to  the  neck  of  the  inhaler. 
The  cushion  is  inflated  through  the  little  tube.  The  best  adapta- 
tion to  the  face  is  obtained  when  it  is  only  partially  distended. 

Liquid  Nitrous  Oxide.* 

This  form  has  been  found  so  convenient,  that  with  many  phy- 
sicians and  dentists  it  has  taken  the  place  of  the  gaseous  form. 
One  of  the  best  forms  of  valve  is  the  Johnston  Gas- Valve 
(Plate  8). 

Description. — The  seat,  A  (shown  by  the  V-shaped  dotted 
line),  is  made  of  a  soft  alloy,  which  easily  receives  the  impress 
of  the  plug,  and  of  course  the  impress  must  exactly  fit  the  point 
which  makes  it.  It  can  be  easily  operated  by  a  child  with  a 
small  wrench. 

The  plug  is  made  in  two  pieces,  B  and  C,  united  by  a  ball- 
and-socket  joint,  so  that  the  moment  the  point  touches  the 
seat,  it  is  prevented  from  revolving,  and  the  rotary  motion 
takes  place  at  the  ball  joint,  thus  preventing  any  wear  or 
grinding  on  the  seat. 

The  cock,  D,  unscrews  from  the  seat,  exposing  the  latter  for 
inspection  or  repair. 

■Projecting  from  the  end  of  the  plug,  down  into  the  gas  pas- 
sage, is  a  long  and  slightly-tapering  point;  this  nearly  closes 
off  the  opening,  even  after  the  plug  is  raised  from  its  seat,  and 
there  is  no  anaoying  rush  of  gas,  even  when  the  plug  is  raised 
several  turns. 

•  Under  a  pressure  of  50  atmospheres,  at  45°  F.,  the  nitrous  oxide  gas  is  condensed 
by  a  pump  into  a  clear,  transparent  liquid,  while  the  cylinders  are  kept  in  ice. 


INHALER   FOR   NITROUS   OXIDE. 


127 


The  valve  is  handsomely  finished  and  nickel-plated  exter- 
nally, and  discharges  through  the  yoke  in  a  manner  readily  un- 
derstood from  the  cut.     It  is  operated  by  a  small  hand-wheel  or 

Plate  8. 


wheel-key,  which  is  provided  with  a  set-screw  to  secure  it  in  po- 
sition, and  thus  avoid  all  danger  of  its  dropping  off,  which  might 
otherwise  occur  at  the  most  critical  moment  in  an  operation. 

By  the  use  of  a  prop,  one  has  a  fair  opportunity  to  per- 
form the  operation  to  his  entire  satisfaction  ;  but  without  it, 
there  is  danger  of  the  patient  bruising,  and  possibly  breaking 
the  front  teeth,  by  biting  so  hard  upon  the  mouth-piece,  when 
recovering  from  the  effects  of  the  gas,  before  the  mouth  can  be 


128  ARTIFICIAL   ANESTHESIA. 

opened  sufficiently  wide  to  admit  of  the  extraction  of  a  tooth, 
or  an  operation  upon  the  mouth. 

Nitrous  oxide  must  always  be  pure  to  insure  success,  though 
some  have  recommended  it  after  it  has  stood  over  water  one 
or  two  weeks,  and  even  a  month ;  but  it  is  impracticable. 
This  is  obviated  in  the  liquid  gas. 

Nickel-plated  Gasometer  and  Ornamental  Stand. 

Plate  9,  represents  a  nickel-plated  gasometer,  mounted  on 
a  stand,  with  a  500-gallon  cylinder  in  position  for  those  who 
may  desire  a  highly  ornamental  piece  of  office  furniture,  coupled 
with  a  really  economical  gas  apparatus. 

In  employing  liquid  gas,  allow  a  certain  amount  of  space 
above  the  liquid  for  expansion  of  the.  gas  when  subjected  to 
varying  temperatures.  The  S.  S.  White  Dental  Manufacturing 
Co.,  has  found  that  in  a  cylinder  containing  512  gallons  of  gas, 
submitted  to  a  temperature  of  95°  Fahrenheit,  the  pressure 
indicated  on  the  gauge  was  3200  lbs.,  and  that  in  the  same 
cylinder,  when  the  quantity  of  gas  was  reduced  to  452  gallons, 
and  subjected  to  the  same  temperature,  the  pressure  was  reduced 
to  1725  pounds  to  the  square  inch. 

They,  for  this  reason,  refuse  to  put  more  than  from  450  to  452 
gallons  in  500-gallon  cylinders.  These  500-gallon  cylinders,  are 
designed  for  those  who  use  large  quantities  of  nitrous  oxide. 

DiKECTioxs. — Use  a  single  leather  washer  on  the  coupling- 
joint  of  the  yoke  attachment. 

The  valve  is  the  only  proper  and  sufficient  means  of  retain- 
ing the  gas;  neither  the  bag  nor  the  inhalers  will  prevent  its 
escape  if  the  valve  is  left  open. 

After  detaching  the  bag  from  the  cylinder,  test  the  valve  to 
be  sure  that  it  is  closed.  This  may  be  readily  ascertained  in  a 
very  simple  way,  as  follows :  Take  a  little  saliva  from  the 
mouth  on  the  finger,  and  gently  pass  it  over  the  outlet  of  the 
valve,  so  as  to  form  a  film  over  the  opening.  If,  because  of 
imperfect  closure  of  the  valve,  there  is  any  escape  of  gas,  the 
film  will  be  forced  outward  in  the  form  of  a  bubble.  A  slight 
turn  more  of  the  hand-wheel,  and  the  film  will  remain  station- 
ary or  show  a  tendency  to  sink  inward  from  the  pressure  of  the 


NICKEL-PLATED    GASOMETER. 

Plate  9. 


129 


NICKEL  PLATED   GASOMETER  AND  ORNAMENTAL  STAND 


130  AllTlFICIAL  ANAESTHESIA. 

external  air,  proving  that  there  is  no  escape  of  gas.  Should 
any  difficulty  be  experienced,  the  cylinder  should  be  returned 
at  once. 

Cylinders  containing  gas  should  never  be  exposed  to  heat,  as 
that  greatly  increases  the  pressure. 

Always  close  the  valve  after  emptying  the  cylinder. 

The  usual  quantity  of  gas  given  to  a  patient,  is  from  3  to  5 
gallons. 

If  it  is  desirable  to  keep  the  patient  under  the  influence  of 
the  anaesthetic  for  a  prolonged  period,  (as  in  a  surgical  opera- 
tion) the  operator,  has  under  his  control  500  gallons  of  gas,  by 
merely  turning  the  key,  seen  in  the  cut  at  the  right. 

On  the  bell  of  the  gasometer,  there  is  a  scale,  graduated  in 
gallons,  and  fractions  of  a  gallon,  so  that  the  operator  can 
readily  see  how  much  gas  he  has  administered. 

Another  valuable  feature  of  this  gasometer  is  a  peculiar 
water-check  or  valve,  so  arranged  that  though  the  gas  flows 
freely  on  the  slightest  inspiration  at  the  inhaler,  it  is  instantly 
and  automatically  shut  off  by  the  water,  when  the  patient 
stops  breathing.  This  prevents  all  waste  of  gas;  it  also  saves 
the  surgeon's  or  dentist's  time  at  the  most  critical  moment,  as 
he  has  only,  after  having  administered  the  gas,  to  lay  aside  the 
inhaler  and  proceed  at  once  to  operate  without  the  necessity 
of  shutting  any  stop-cock.  The  stand  is  so  constructed  that  a 
small  (10-gaIlon)  cylinder  can  be  used  while  the  larger  cylinder 
is  being  refilled. 

We  also  call  attention  to  the  fact,  that  there  is  no  liability 
to  loss  of  gas  from  leakage,  caused  by  the  operator's  leaving 
the  valve  of  the  cylinder  open,  for,  if  there  is  such  escape 
from  the  cylinder,  the  bell  of  the  gasometer  will  rise,  and  the 
operator  having  his  attention  called  to  the  waste,  will  be  en- 
abled to  correct  the  difficulty  at  once. 

The  gas  can  be  kept  for  any  length  of  time,  and  is  constantly 
on  hand  and  always  of  the  best  quality. 

The  diagram  (Plate  10)  represents  a  sectional  view  of  a 
nickel-plated  gasometer. 

Two  metallic  cylinders,  AA,  are  arranged  concentrically  to 
form  a  water-holding  space  between  their  approximating  walls, 


NITROUS  OXIDE  GAS   CYLINDERS. 


131 


while  a  third  cylinder,  having  a  cover  with  a  guide-rod,  C,  at- 
tached to  the  cover,  is  lowered  into  the  water-space  as  a  seal 
between  the  cylinders,  and  to  form  a  gas-chamber,  D,  at  the 
top.  The  inner  cylinder  is  provided  with  a  central  tubular 
cavity,  closed  at  the  bottom,  to  receive  the  guide-rod  of  the 
cover. 

It  is  obvious  that  the  chamber,  D,  will  be  enlarged  or  dimin- 
ished according  to  the  volume  and  pressure  of  the  gas,  which 
rises  to  the  chamber  from  the  iron  cylinder,  E,  beneath  the 

Plate  10, 


,>AA 


gasometer,  when  the  valve  is  opened,  through  the  connecting 
tube  and  pipe,  FF.  The  gas  is  conducted  to  the  inhaler  from 
the  chamber,  D,  through  a  closed  cylindrical  water-vessel,  G, 
attached  to  the  wall  of  the  inner  cylinder,  and  provided  with 
an  inlet  pipe,  H,  and  an  outlet  pipe,  I,  which  latter  is  carried 
to  the  outside  at  right  angles  to  the  gasom.eter,  and  receives  the 


132  ARTIFICIAL   ANAESTHESIA. 

tubing  which  conducts  the  gas  to  the  inhaler.  This  closed 
vessel  G,  is  also  provided  with  a  water  outlet  or  overflow,  J, 
and  the  whole  forms  a  very  simple  and  effective  trap  for  shut- 
ting off  the  gas  when  not  inhaled.  In  operation,  it  is  only 
necessary,  before  the  cover  is  placed  in  position,  to  pour  into 
the  water-space  between  the  cylinders,  enough  water  to  nearly 
fill  it,  and  into  the  inlet  pipe,  H,  sufficient  water  to  overflow 
the  outlet,  J,  or  the  trap,  the  rubber  stopper,  K,  of  the  latter 
being  removed  for  that  purpose  and  replaced  when  the  overflow 
has  ceased.  Then  insert  the  cover,  and  open  the  valve  of  the 
iron  cylinder  beneath. 

The  vacuum  in  the  vessel,  G,  produced  by  each  inhalation  is 
immediately  filled  by  the  gas,  passing  through  the  water  and 
upward  to  the  outlet,  I ;  the  instant  that  inhalation  ceases,  the 
gas  is  arrested  and  confined  at  the  water-level  in  the  trap. 

DiBECTIONS  FOK  SETTING  IJP  AND  USING  THE  GASOMETER. 

— Unpack  carefully  the  two  boxes,  removing  all  the  hay  from 
the  smaller  one  before  trying  to  lift  the  gasometer  from  the  box. 
Lift  the  top  (bell)  of  the  gasometer  clear  of  the  water-tank,  and 
set  the  plated  tank  on  top  of  the  iron  stand,  placing  it  so  that 
the  tube  underneath,  to  which  the  inhaler  tubing  is  to  be  at- 
tached, shall  come  exactly  opposite  the  small  hole  provided  in 
the  iron  base.  With  a  cup  or  dipper,  fill  the  annular  space  in 
the  body  of  the  gasometer  (tank)  with  water  to  within  three 
inches  of  the  top,  and  pour  about  a  pint  of  water  into  the  trap 
through  the  large  tube  seen  in  the  top  of  the  gasometer. 

To  Adjust  for  a  500-gallon  Cylinder. — Secure  the  wider  of  the 
two  iron  rings  in  position  near  one  of  the  feet  of  the  stand  by 
means  of  the  screw  provided  for  the  purpose.  Keeping  the 
large  cylinder  horizontal  (the  stop-cock  end  may  rest  on  the 
floor),  place  the  bottom  of  the  cylinder  in  the  ring,  being  care- 
ful, of  course,  not  to  drop  the  cylinder,  and  observing  that  the 
delivery  opening  of  the  stop-cock  is  to  the  right. 

Now  slide  the  other  iron  ring  over  the  top  of  the  cylinder, 
and  elevate  this  end,  at  the  same  time  adjusting  the  ring  so 
that  the  projection  on  its  side  will  enter  the  slot  provided  for 
it  under  the  centre  of  the  gasometer,  and  allow  the  pin  to  be 
put  in  place,  securing  it  in  position.    Tighten  the  set-screws  in 


NITROUS   OXIDE   GAS   CYLINDERS.  133 

the  upper  ring  against  ttie  cylinder,  using  the  key  sent  with 
the  apparatus,  so  that  it  cannot  turn  around  when  the  stop-cock 
is  opened  or  closed. 

To  Adjust  for  a  100-gallon  Cylinder. — It  is  only  necessary  to 
slide  the  cylinder  to  its  place  horizontally  through  the  opening 
in  the  side  of  the  iron  base,  keeping  the  delivery  opening  of 
the  stop-cock  toward  the  right,  fastening  it  in  position  by  means 
of  the  long  set-screw  which  projects  though  the  side  of  the  iron 


In  either  case  (whether  a  100-  or  a  500-gallon  cylinder)  screw 
the  yoke  which  will  be  found  attached  to  a  rubber  tube  under 
the  gasometer  to  its  place  on  the  stop-cock  of  the  cylinder,  be- 
ing sure  that  there  is  a  leather  washer  properly  placed  on  the 
union  tube.  A  leather  washer  will  be  found  attached  to  every 
cylinder.  This  must  be  attended  to  every  time  a  new  cylinder  is 
placed  in  position. 

Draw  the  small  rubber  stopper  from  the  end  of  the  tube  under 
the  gasometer,  and  allow  all  the  water  that  will,  to  flow  from 
the  tube  into  a  basin  or  pail,  and  then  replace  the  cork  tight. 

Now  (and  not  before)  return  the  bell  to  its  place,  being  care- 
ful to  enter  the  central  rod  and  the  graduated  scale  into  their 
respective  guides.  After  the  slight  spluttering  around  the  edge 
of  the  bell  is  over,  if  the  foregoing  directions  have  been  fol- 
lowed properly,  the  bell  will  remain  balanced,  and  a  very  slight 
(a  few  ounces  on]\ )  pressure  of  the  hand  on  its  top,  will  cause 
it  to  settle  gradually. 

Before  letting  gas  into  the  gasometer,  force  the  bell  entirely 
down,  to  remove  all  air.  It  is  well  to  let  in  a  few  gallons  of 
gas,  and  to  force  this  out  also,  so  as  to  expel  the  last  traces  of 
air  from  the  gasometer.  Nov/  attach  the  inhaler  and  tubing  to 
the  gasometer,  by  sliding  the  connection  on  the  end  of  the 
tubing  firmly  to  its  place  through  the  hole  in  the  side  of  the 
iron  base ;  then  with  the  nickel-plated  cap  cover  the  opening 
through  which  the  100-gallon  cylinder  goes  to  its  place,  and 
the  apparatus  is  complete. 

Directions  for  Using. — To  let  gas  into  the  gasometer,  open 
the  stop-cock  on  top  of  the  cylinder  with  the  key.  The  stop- 
cock of  both  the  100-  and  500-gallon  cylinders  can  be  reached 


134  ARTIFICIAL  ANAESTHESIA. 

through  the  hole  in  the  centre  of  the  nickel-plated  cap  men- 
tioned above. 

The  numbers  on  the  graduated  scale  indicate  gallons,  and 
enable  one  to  determine  the  amount  of  gas  used  by  each  pa- 
tient ;  thus,  if  10  appears  just  at  the  top  of  the  water-tank  when 
beginning  to  administer  the  gas,  and  after  the  administration  6 
stands  at  the  same  place,  4  gallons  of  gas  have  been  used. 

We  would  suggest  that  in  beginning  the  use  of  this  apparatus 
a  record  be  kept  of  the  number  of  gallons  of  gas  used  by  each 
patient. 

When  liquid  gas  is  used,  5  gallons  is  sufficient  for  ordinary 
dental  operations. 

When  the  ordinary  gas  as  made  by  dentists  is  used,  an  aver- 
age quantity  of  about  eight  gallons  is  necessary. 

After  administering  the  gas,  it  is  unnecessary  to  stop,  to  shut 
the  stop-cock  of  the  inhaler  before  commencing  the  operation, 
as  the  trap  will  shut  off  the  gas  automatically;  it  is  well,  how- 
ever, to  shut  the  stop-cock  immediately  upon  completing  the 
operation,  as  otherwise  the  tubing  will  fill  with  air,  which  will 
interfere  with  the  next  administration. 

A  large  hook  will  be  found  under  the  gasometer,  upon  which 
the  coiled  inhaler  tubing  may  be  hung,  when  it  is  desired  to 
set  the  apparatus  out  of  the  way. 

Cautions. — 1st.  Do  not  blow  into  the  inhaler  tubing  when  the 
inhaler  is  not  in  place,  as  it  will  derange  the  water- trap. 

2d.  If,  for  any  reason,  it  is  necessary  to  remove  the  bell  from 
its  place,  first  disconnect  the  union  from  the  cylinder,  so  as  to 
admit  air  to  the  gasometer,  and  then  raise  the  bell  gently  and 
slowly. 

WaU-Bracket  for  Gas  Cylinders.— (Plate  11.) 

This  is  an  excellent  device  for  use  in  offices  where  the  gas  is 
administered  frequently.  The  bracket  may  be  attached  to  the 
window-casing  or  other  wood-work.  As  the  wall  bracket  has  a 
yoke  attachment,  it  can  be  arranged  to  a  stand  on  the  floor  of 
the  office.* 

*  For  greater  convenience  a  small  cylinder  is  made,  containing  bag,  inhaler  and 
tubing,  in  a  metal  caae  for  carrying  by  tlie  surgeon  to  tlie  patient's  Louse. 


NITEOUS   OXIDE   GAS. 
Plate  11. 


Nitrous  Oxide  Gas. 

This  anaesthetic  can  be  employed  in  a  few  operations  in  sur- 
gery ;  these  are,  extraction  and  surgical  operations  on  the  teeth 
and  gums.  With  it  the  ophthalmic  surgeon  can  operate  for 
ordinary  strabismus,  or-  removal  of  small  tumors,  or  enucleate 
the  diseased  eyeball.  It  is  very  valuable  in  examining  the  ure- 
thra for  stricture,  and  even  the  cutting  of  an  impervious  stricture 
has  been  performed  under  its  influence  with  success.  Necessary 
manipulation  in  stiff  joint,  and  tenotomy  of  tendons  for  the 
relief  of  club  foot,  etc.,  have  all  been  performed  while  under 
its  influence,  and  in  conjunction  with  sulphuric  ether,  bromide 
of  ethyl,  oxygen  and  chloroform,  almost  all  surgical  operations 
can  be  performed,  even  when  prolonged. 


136  ARTIFICIAL   ANAESTHESIA. 

Nitrous  Oxide  in  Prolonged  Surgical  Operations. 
— At  the  recent  meeting  of  the  American  Medical  Association, 
at  Newport,  R.  I.,  we  had  a  long  and  interesting  conversation 
with  Dr.  C.  A.  Brackett,  the  well-known  distinguished  dentist 
of  that  city,  on  various  matters  concerning  the  discovery  and 
introduction  of  nitrous  oxide.  The  doctor  called  my  at- 
tention to  a- number  of  cases  of  the  prolonged  use  of  this 
agent  in  various  surgical  operations  by  Dr.  Goodwillie,  of  New 
York.  ("  Johnston's  Dental  Miscellany,"  vols.  1  &  3,  p.  85.) 
They  were  sixteen  in  number — comprising  amputation  of  the 
thigh,  removal  of  breast  and  ovarian  tumor,  with  other  less  im- 
portant operations,  all  successful.  There  was  also  an  attempt  at 
reduction  of  the  hip  joint,  but  this  failed.  Owing  to  its  not  re- 
laxing the  muscles  sufficiently,  it  was  discontinued,  and  ether 
substituted.     The  following  were  his  conclusions  : 

The  average  amount  of  gas  used  in  prolonged  anassthesia,  is 
about  two  gallons  per  minute. 

To  keep  up  prolonged  ansesthesia,  requires  great  care  and 
judgment  on  the  part  of  the  ancesthelist.  Anoesthesia  on  the 
one  hand,  and  consciousness  of  pain  on  the  other,  are  condi- 
tions of  the  body  with  respect  to  lime,  that  bear  close  rtlations  to 
each  other,  and  so  judgment,  and  prompt  action  in  adminis- 
tering the  gas  is  required.  The  anresthetist,  in  any  case,  must 
not  allow  his  attention  lo  be  distracted  by  the  patient.  Dr. 
Goodwillie  employed  the  liquid  gas,  and  states,  that  the  first  case 
reported  of  the  use  of  the  liquid  nitrous  oxide  (from  cylinders) 
in  this  country,  was  on  October  13,  1871.  The  inhaler  which 
he  found  most  efficient,  covers  both  mouth  and  nose. 

We  give  the  case  of  Dr.  Brackett  in  full,  as  it  has  never  be- 
fore been  published  : 

A  Copy  from  Private  Eecord  of  C.  A.  Brackett, 
M.D.,  D.D.S.— "April  20th,  1875,  Mrs.  R.  S.,  administered 
nitrous  oxide,  and  kept  patient  under  its  influence  about  thirty 
minutes,  while  Dr.  Squier  removed  cancer  of  the  breast.  Grand 
success.  Patient  not  conscious  of  operation.  I  believe  this  is 
the  first  such  achievement  of  the  kind  in  New  England.  Not 
all  of  one  100-gallon  cylinder  used  oi  Johnston'' s  Liquid  Gas." 

The  patient  receiving  impure  gas,  will  generally  have  some 


ADMINISTEATION   OP   NITROUS   OXIDE   GAS.       137 

undefined  impression  of  the  operation,  and  will  often  complain 
of  giddiness,  a  fulness  in  the  head,  and  a  feeling  generally  of 
malaise  for  the  balance  of  the  day.  With  pure  gas,  sickness  is 
not  apt  to  occur,  except  with  patients  of  very  delicate  organiza- 
tions, such  as  are  easily  disturbed  by  nervous  excitement,  and 
those  who  are  affected  by  the  sight  of  blood,  or  the  contempla- 
tion of  a  wound  of  any  kind. 

Brief  Hints  as  to  the  Proper  Method  of  Adminis- 
tering- Nitrous  Oxide  Gas  as  an  Anaesthetic. 

The  most  important  matter  is  to  have  an  intelligent  male  or 
female  assistant.     It  is  never  safe  to  be  without  one,  or  the  ^ 
other. ''^^rtificial  teeth  must  be  removed,  and  if  the  patient  is 
very  old  or  feeble,  or  there  is  a  fatty  heart,  or  diseased  lungs, 
the  reclining  posture  is  the  safest.     The  ordinary  position  is      /i 
\   the  sitting-up  or  half-reclining.  ' 

y.  The  operator  stands  on  one  side,  and  carefully  introduces  >N 
^  between  the  teeth  a  prop  of  wood  or  hard  rubber,  to  which  is 
attached  a  string.  The  patient's  dress,  if  a  female,  is  opened 
and  the  cravat  is  loosened  in  the  male.  Everything  should 
be  done  without  undue  haste.  Nor  should  any  noise  or  loud 
talking  be  allowed  in  the  operating-room.  The  inhaler  is 
then  placed  between  the  lips  and  teeth  of  the  individual  to  be 
operated  upon,  and  the  nose  is  clasped  between  the  two  fingers, 
if  there  is  no  face-piece  employed.  The  gas  is  now  turned  on,  and 
the  patient  is  directed  to  let  the  mind  dwell  on  some  pleasant 
object— -occasionally  we  have  found  a  few  notes  from  a  musical- 
box  very  agreeable  when  the  patient  is  reviving.  If  there  is  a 
face-piece  to  the  inhaler,  it  is  to  be  gently  applied,  with  just 
sufficient  pressure  to  prevent  the  escape  of  the  gas,  and  the 
patient  is  directed  to  make  slow  and  deep  breathing.  Keep 
the  bag  full  of  gas.  Let  the  assistant  watch  carefully  the  pulse 
and  respiration,  opening  the  ingress  of  the  gas  during  inspira- 
tion, and  closing  it  during  expiration. 

Usually  it  requires  from  twenty  to  twenty-five  seconds  to  fill 

the  lungs  with    the  gas ;    then  appears  pallor  of  the  skin, 

with  darkening  of  the  nails  and  finger  tips,  yet  consciousness 

ts^    may  be  still  present,  and  the  inhalation  may  have  to  be  con- 


138 


ARTIFICIAL   ANESTHESIA. 


V\ 


tinued  from  five  to  ten  seconds  longer.  In  about  half  to  three 
quarters  of  a  minute,  the  patient's  consciousness  is  lost,  and 
soon  after  the  pupils  will  dilate,  the  eyes  becoming  dull,  with 
loss  of  expression,  and  there  may  be  strabismus.  This  is  the 
primary  condition  of  ansesthesia,  when  if  the  conjunctiva  is 
touched,  the  reflex  is  still  there,  and  yet  at  this  stage,  a  single 
tooth,  or  a  very  slight  operation  can  be  performed.  If,  how- 
ever, the  inhalation  is  continued  for  a  minute  longer,  the 
breathing  becomes  stertorous,  muscular  movements  of  the 
hands  and  feet  take  place,  and  the  conjunctiva  can  be  touched 
without  any  movement.  Should  the  breathing  stop  for  more 
than  ten  seconds  air  must  be  given.  This  is  the  period  of  deep  an- 
sesthesia,  and  should  the  heart  intermit,  and  pulse  at  the  wrist 
not  be  felt,  air  must  be  introduced  and  the  gas  stopped.  If  every- 
thing remains  in  good  condition,  now  is  the  time  for  operation.  // 

Sphyg-mographic  Tracings  from  Patients  under 
the  Influence  of  Nitrous  Oxide  Gas.* 

"  It  is  well  known  that  as  soon  as  the  inhaler  ia  placed  over  the 
mouth  and  nose  of  the  patient,  he  begins  to  respire  more  quickly 
Plate  12— (Figs.  1-3.) 


NORMAL   PULSE. 


FULLY  UNDER  NITROUS  OXIDE  WITH  LOWERING  OF  ARTERIAL 

TENSION. 

*  Abstract — "The  Effects  of  Nitrous  Oxide  on  the  Pulse,"  by  Daniel  Mowat,  M.B. 
and  0.  M.  Edin,  Journal  Britith  Dental  Association,  March  1887,  p.  144. 


ADMINISTEATION   OF   NITROUS   OXIDE   GAS.       139 


TIDAL   WAVE   APPEARING. 

and  his  pulse  increases  in  speed.  This,  however,  is  due  to  ex- 
citement resulting  from  the  fear  which  usually  accompanies 
the  inhalation.  As  soon  as  inhalation  begins  respiration  be- 
comes slow,  the  tension  of  the  pulse  falls,  the  number  of  beats 
per  minute  is  increased,  the  tidal  or  predicrotic  wave  is  slightly- 
better  marked,  and  the  dicrotic  wave  becomes  so  well  marked 
as  to  constitute  that  pulse  which  is  known  as  fully  dicrotic; 
sometimes,  indeed,  it  is  even  slightly  hyperdicrotic.  As  anaes- 
thesia proceeds  the  tension  of  the  pulse  falls  considerably, 
whilst  the  number  of  pulsations  increases.  The  tidal  and  di- 
crotic waves  still  remain  very  well  marked.  When  the  mouth- 
piece is  removed  and  any  operation  is  to  be  performed,  the 
pulse  undergoes  a  marked  change.  This  is  probably  due  to  a 
reflex  action  through  the  vagus  to  the  heart.  Immediately 
after  the  operation  the  pulse  gradually  assumes  its  normal  con- 
dition, passing  (in  the  reverse  order)  through  the  stages  it  had 
undergone  when  the  nitrous  oxide  gas  was  applied. 

As  a  matter  of  course,  every  patient  is  a  law  unto  himself 
as  regards  the  time  required  to  come  fully  under  the  influence 
of  the  anaesthetic,  and  even  the  same  individual  will  diff"er  at 
different  conditions  of  the  system. 

The  Committee  appointed  by  the  Odontological  Society  of 
Great  Britain,  found  the  following  averages  in  a  laige  number 
of  administrations  of  the  gas:     (Buxton.) 


Males, 

Females, 

Children  (under  15), 


Time  going  off. 


1  min.  21  sec. 
1     "     16    " 
1     «       3    « 


24  sec. 
28    " 
22   " 


Time  from  com- 
mencement to 
recover}'. 


1  min.  55  sec. 

2  " 

1     "     49     " 


140  ARTIFICIAL   ANJESTHESIA. 

For  emergeucics,  the  operator  or  his  assistant  should  have 
within  reach  a  napkin  to  draw  out  the  tongue,  an  artery  forceps 
to  hold  it  if  necessary,  nitrite  of  amyl  in  case  of  extreme  pale- 
ness, but  not  if  much  flushed.  Above  all,  to  be  able  to  invert 
the  patient  so  that  the  blood  will  reach  the  antemic  brain,  or 
place  him  on  the  floor,  opening  the  windows  and  performing 
artificial  respiration.  Stertor,  with  slight  jactitation,  are  signs 
that  the  patient  is  ready  for  operation,  and  is  caused  by  vibra- 
tion of  the  arytajno-epiglottidean  folds.  This  comes  on  after 
at  least  a  minute,  and  must  not  be  confounded  with  the  "snor- 
ing "  of  patients  who  suffer  from  enlarged  tonsils  or  pt)st-na8al 
adenoid  growths. 

The  evidence  of  returning  consciousness  is  the  normal  color 
in  the  face  and  lips,  with  a  cry  or  movement  of  the  hands.  For 
long-continued  operations  in  dental  surgery,  or  any  surgical 
operation,  a  combination  of  ether  and  nitrous  oxide  is  one  of 
the  best. 

The  following  is  the  improved  apparatus  of  Clover  for  nitrous 
oxide  and  ether.     This  is  seen  in  Plate  13.     (Buxton.) 

It  consists  of  a  tripod  supporting  a  cast-iron  bottle  containing 
fifty  gallons  of  nitrous  oxide  gas,  the  bottle  being  gripped 
firmly  by  a  screw.  The  supply  is  regulated  by  the  adminis- 
trator's foot,  which  is  placed  upon  the  foot-piece,  K.  This  is 
provided  with  teeth  which  bite  into  the  boot,  and  enable  the 
administrator,  by  turning  his  foot  to  the  left,  to  open  the  outlet 
of  the  gas.  E  is  the  connection  between  the  bottle  and  the 
Cattlin  bag,  G. 

The  small  metallic  receiver  can  be  filled  with  warm  water  to 
obviate  freezing  of  the  gas  in  cold  weather.  The  India-rubber 
tube  will  be  seen  to  fix  on  a  stop-cock  in  front  of  the  ether 
receiver,  which  latter  is  suspended  by  a  hook  from  the  admin- 
istrator's coat.  When  only  gas  is  to  be  given,  the  stop-cock  on 
the  ether  vessel  is  put  at  right  angles  to  the  long  axis  of  the 
bag;  when  ether  is  to  be  used,  this  stop-cock  is  turned  into  the 
long  axis  of  the  bag.  The  stop-cock  in  front  of  the  ether- 
receiver  is  more  conveniently  placed  just  above  where  the  tube 
is  seen  to  end.  The  Cattlin  bag  is  so  arranged  as  to  allow  of 
pure  nitrous  oxide,  pure  ether,  or  a  mixture  of  these  two  sub- 


clovee's  apparatus. 


141 


stances  to  be  administered.  The  supply  is  regulated  directly 
by  the  stop-cocks  above-mentioned,  but  more  immediately  by 
an  arrangement  represented,  though  not  very  clearly,  at  Ee. 
It  consists  of  a  semi-circle  of  plated  metal,  upon  which  are 
engraved  at  opposite  ends  the  letters  G  and  E.  An  indicating 
rod  plays  upon  this  by  simply  shifting  the  indicator,  so  that  it 
revolves  free  of  the  semi-disc,  and  the  air  is  inspired.     When  the 

Plate  13. 


indicator  points  to  G,  nitrous  oxide  passes  into  the  face-piece, 
and  as  the  indicator  travels  toward  F,  ether  vapor  is  permitted 
to  mix  with  the  gas  until  arriving  fully  at  E,  when  pure  ether  is 
inhaled.  The  cushioned  face-piece  is  used  by  Clover,  and  is 
supplied  with  a  simple  expiratory  valve. 

Should  a  supplemental  bag  be  used,  the  face-piece  must  be 
provided  with  an  aperture  to  which   this  accessory  can  be 


142 


ARTIFICIAL   ANiESTIIESIA. 


adjusted.  The  stop-cock  in  this  arrangement  is  kept  shut 
until  the  residual  air  of  the  lungs  is  presumably  exhausted, 
when  it  is  opened,  the  finger  placed  upon  the  expiratory  valve, 
and  the  patient  allowed  to  breathe  backwards  and  forwards 
into  the  bag. 

When  desirable,  according  to  "  Buxton,"  it  is  a  simple  matter 
to  convert  the  Cattlin  bag,  into  a  supplemental  bag,  by  placing 
a  finger  upon  the  expiratory  valve,  and  so  causing  the  patient 
to  expire  back  into  the  Cattlin,  as  well  as  inspiring  from  it. 

Where  a  gasometer  is  employed,  as  in  the  case  of  Dr.  Thomas, 
of  Philadelphia,  and  others,  a  modification  of  the  above  appa- 
ratus may  be  used. 

A  long  tube  screws  on  to  the  efferent  pipe  of  the  gasometer, 
conveying  the  gas  to  a  bag  of  two  or  three  gallons'  capacity. 
This  may  be  connected  directly  with  a  face-piece,  or  conveyed 
to  it  by  another  length  of  tubing,  and  by  using  a  three-way 
cock,  it  is  easy  to  combine  this  apparatus  in  gear  with  Clover's 
smaller  ether  inhaler. 

Clover's  Small  Portable  Ether  Apparatus. 

(For  description,  see  Inhalers). 
Plate  14  (Buxtou). 


Attachments  fov  gas  cylinders  have  been  devised  in  this 
country  by  Lewis,  of  Buffalo,  and  by  Dr.  A.  M.  Long,  in  which 


NITROUS   OXIDE    AND    ETHER.  143 

the  gas  is  made  to  combine  with  the  vapor  of  other  anaesthetics, 
such  as  chloroform,  ether,  etc.  The  latter  has  a  combining- 
chamber  through  which  the  gas  passes  from  the  cylinder  on  its 
way  to  the  gasometer.  There  is  a  receptacle  for  the  liquid 
agent.  When  a  handle  below  is  turned  half-way  round,  the 
two  separate  tubes  meet,  and  drop  by  drop  the  liquid  passes 
into  the  combining-chamber. 

In  the  following  statements,  published  by  "  Guilford  "  (p.  82, 
Nitrous  Oxide),  we  omit  those  on  chloroform,  as  we  consider 
such  a  combination  highly  dangerous,  but  in  the  case  of  ether, 
there  is  so  much  less  danger,  that  we  favor  at  times  a  mixture, 
as  in  the  following  cases. 

A  gentleman  writes  (name  not  given,  but  known  to  Dr. 
Guilford) : 

"I  have  used  nitrous  oxide  for  eighteen  years,  and  during  the  past 
five  years  have  given  it  in  combination  with  chloroform  or  ether.  For 
the  last  two  years  I  have  used  '  Squibb's  '  ether  instead  of  chloroform, 
and  prefer  it.  I  combine  from  fifteen  to  twenty-five  drops  of  the  ether 
with  five  gallons  of  the  gas.  By  using  the  combination,  I  can  extract 
as  many  as  sixteen  teeth  and  roots,  at  one  time,  whereas,  with  the  gas, 
I  have  seldom  been  able  to  remove  more  than  five  or  seven.  Patients 
seem  to  recover  from  the  efi'ects  of  the  combination  as  quickly,  as  from 
the  gas.  I  have  had  no  nausea  or  other  unpleasant  effects  to  follow 
its  administration.  I  cannot  suppose  a  case  where  it  would  be  proper 
to  give  the  gas,  in  which  1  would  hesitate  to  administer  the  combi- 
nation." 

Codman  &  Shurtleff,  of  Boston,  have  devised  an  inhaler  for 
nitrous  oxide  gas  or  ether.  This  is  accomplished  by  simply 
changing  the  arrangement  of  the  mouth-pieces,  and  is  described 
and  figured  under  inhalers. 


w 


Tlie  Physical  Properties  and  Physiological  Action  of 
Xitrog-eii  Monoxide— Xitro VIS  Oxide  (IfO-XjO). 

Nitrous  oxide  gas,  when  pure,  should  be  free  from  color  or 
odor.  It  has  a  sweetish  taste.  It  is  an  active  supporter  of 
combustion.  A  taper  will  burn  in  it,  but  the  decomposition 
of  the  nitrous  oxide,  is  due  to  the  high  heat,  for  at  the  ordi- 
nary temperature  of  the  body  it  is  not  decomposedv^Seeds 


\\ 


144  ARTIFICIAL    ANESTHESIA. 

will  not  germinate  in  it,  and  animals  live  no  longer  in  this 
atmosphere,  than  in  one  of  nitrogen.  During  nitrous  oxide 
narcosis,  the  amount  of  carbonic  acid  exhaled  from  the  lungs, 
is  only  two-thirds  of  that  eliminated  before  the  inhalation. 
It  has,  however,  the  one  quality  of  producing  a  sense  of  ex- 
hilaration and  true  anaesthesia,  which  no  other  mixture  of 
nitrogen,  carbonic  acid,  air  or  of  oxygen,  can  produce,  proving 
that  the  theory  of  asphyxia  is  not  the  true  one,  the  circulation 
having  been  found  very  differently  affected  by  mechanical  or 
chemical  agents,  than  by  nitrous  oxide. 

Nitrous  oxide  gas  should  be  kept  in  a  liquid  state,  or 
made  freshly,  for  it  is  a  well-known  and  recognized  fact  that 
if  kept  over  water,  it  absorbs  nearly  its  own  bulk.  We 
have  before  expressed  our  opinion,  that  when  the  gas  is 
administered  in  its  pure  state,  it  enters  the  air-cells  of  the 
lungs  and  circulates  in  the  blood.  In  confirmation  of  the 
above,  Dr.  C.  A.  MacMunn  ("  The  Spectroscope  in  Medicine," 
London,  1880,  pp.  73-75)  finds  that  when  an  animal  is  killed 
by  nitrous  oxide  the  arterial  blood  gives  only  spectrum  lines 
of  reduced  haemoglobin,  while  after  chloroform  those  of 
oxyhcemoglobin  are  very  apparent. 

The  marked  resemblance  between  the  effects  produced  by 
nitrous  oxide,  and  those  resulting  from  asphyxia,  were  ob- 
served by  the  earlier  experimenters  with  ether,  and  a  few 
eminent  physiologists  at  once  expressed  the  opinion,  that  the 
physiological  action  was  the  same  ;  but  at  the  present  day  this 
is  not  generally  entertained. 

The  following  is  a  summary  of  the  various  facts  bearing  on 
the  subject,  i.e.,  in  regard  to  the  physiological  action  of  ni- 
trous oxide. 

It  would  seem  that  this  accumulated  evidence  is  not  suffi- 
cient to  show  that  the  antesthesia  produced  by  the  inhalation 
of  nitrous  oxide,  is  simply  asphyxia.  Nitrous  oxide  gas  pro- 
duces in  man,  even  when  mixed  with  air,  a  feeling  of  exhil- 
aration, and  stimulation,  which  would  indicate  that  it  is  not 
merely  a  passive  agent,  and  then  acts  as  a  narcotic.  The 
discolored  appearance  of  the  patient  while  under  its  influ- 
ence is,  to  a  great  extent,  due  to  the  accumulation  of  carbonic 
acid  in  the  biood. 


INHALATION   OF   NITROUS   OXIDE.  145 

Nitrogen,  when  inhaled,  acts  upon  the  animal  economy,  not 
solely  by  the  exclusion  of  oxygen.  When  nitrogen  is  taken 
into  the  lungs  it  gives  rise  to  no  feeling  of  exhilaration,  but 
sometimes  to  malaise,  and  a  sense  of  impending  suffocation. 

After  death,  which  has  been  very  rare  from  nitrous  oxide, 
the  following  is  the  condition  of  the  lungs  :  these  organs  are 
found  neither  voluminous,  nor  collapsed ;  of  a  light  pink  or  rose 
color,  and  generally  with  one  or  more  small  circular,  well-de- 
fined ecchymotic  spots,  usually  on  their  posterior  surface. 

The  lungs  are  moderately  crepitant,  and  the  blood  which, 
escapes  from  an  incision,  is  more  or  less  full  of  gas  bubbles. 
These  bubbles  will  be  found  in  the  bronchial  ramifications 
mixed  with  mucus,  and  in  one  or  two  instances,  the  trachea  was 
filled  with  rusty,  frothy  fluid,  so  common  after  drowning. 

The  local  effects  of  nitrous  oxide  were  found  to  be  like  those 
produced  by  carbonic  acid. 

They  both  act  upon  the  blood-corpuscles  so  as  to  darken 
them.  The  lividity  upon  the  lips,  and  the  darkening  of  the 
mucous  surfaces,  seen  every  day  in  the  operating-room,  after  ad- 
ministration of  nitrous  oxide,  are  the  result  of  this  action.  The 
inhalation  of  nitrous  oxide,  is  followed  by  an  increased  exhala- 
tion of  carbonic  acid,  until  a  certain  point  is  reached,  when  it 
diminishes ;  so  also  is  the  inhalation  of  ether,  chloroform,  etc. 

The  conditions  which  are  obtained  after  the  inhalation  of 
nitrous  oxide,  ether,  chloroform,  and  other  anaesthetics,  are 
specific  toxical  properties,  which  ^rs^  stimulate,  then  narcotize, 
then  destroy  nervous  action — by  {a)  an  interference,  more  or 
less  marked,  with  the  oxygenation  of  the  blood,  and  the  con- 
sequent imperfect  accomplishment  of  certain  chemico-vital 
processes;  by  (6)  a  retention  in  the  blood  of  a  portion  of  the 
usual  pulmonary  exhalations,  carbonic  acid,  etc.,  these  sec- 
ondary conditions  always  finally  co-operating  with  the  specific 
action  of  the  anaesthetic  in  the  production  of  narcosis,  the 
arrest  of  innervation,  and  in  the  suspension  of  every  functional 
movement  for  a  time,  with  a  rapid  return  to  health.  Latterly  it 
has  been  proved,  both  by  experiment  and  observation,  that  the 
theory  which  for  a  time  prevailed  in  the  United  States,  "  that 
nitrous  oxide  acts  upon  the  blood  as  an  oxygenating  agent,"  is 
7 


146 


ARTIFICIAL   AN/ESTHESIA, 


incorrect.  No  experimental  proof  has  yet  been  furnished  that 
nitrous  oxide  is  decomposed  in  the  blood,  or  forms  chemical 
combinations  with  it.  It  enters  into  the  blood  as  nitrous  oxide, 
and  as  such  is  eliminated.  It  will  naturally  be  inferred  from 
this  statement,  that  the  presence  of  nitrous  oxide  in  the  blood 
is  not  indicated  by  the  appearance  (except  change  of  color), 
as  before  stated.  This  was  first  very  conclusively  proven  by 
the  late  Dr.  J.  H.  McQuillen,  Professor  of  Physiology,  in  the 
Philadelphia  Dental  College,  which  proofs,  are  here  given  with 
the  illustrations. 

The  late  Dr.  F.  R.  Thomas,  of  this  city,  placed  his  whole 
apparatus,  with  a  large  supply  of  recently-made  pure  nitrous 
oxide  gas,  at  the  disposal  of  Dr.  McQuillen  and  the  writer,  and 
we  repeated  the  experiments  in  confirmation  of  the  facts  :  that 
the  gas  had  no  positive  poisonous  qualities;  second,  that  the 
blood-corpuscles  were  changed,  neither  in  form  nor  color,  under 
the  microscope,  and  nitrous  oxide  is  only  known  by  the  change 
of  color,  and  even  this  varies  much  in  individuals. 

First  Series. — The  experiments  were  as  follows:  —  In  our 
examinations  of  the  blood  of  man   and  animals,  when  ether 

and  chloroform  were  brought 
in  direct  contact  with  it  out 
of  the  body,  under  a  fifth  ob- 
jective, the  discharge  of  the 
nuclei  and  the  disintegration 
of  the  corpuscles  have  invaria- 
bly occurred,  and  in  the  frog 
leaving  a  result  similar  to  that 
which  is  presented  in  the  ac- 
companying drawing  (Plate  15) 
from  one  of  my  specimens, 
wherein  it  will  be  observed  that 
the  field  is  occupied  by  the  nu- 
clei, debris  of  disintegrated 
globuline  and  corpuscles,  in 
which  the  clmnge  of  form,  size  and  other  characteristics  are 
most  striking. 
Second  Series. — On  placing,  however,  two  glass  slides  con- 


Plate  15. 


Frog's  blood  placed  upon  the  slide,  and 
chloroform  brought  in  direct  contact 
with  it. 


EXPOSURE   TO   CHLOROFORM   OR   ETHER. 


147 


taining  frog's  blood  over  watch-crystals,  one  holding  chloro- 
form and  the  other  ether,  and  covering  them  with  glass  finger- 
bowls  for  half  an  hour,  thus  exposing  one  to  aa  atmosphere  of 
ether,  and  the  other  of  chloroform,  we  found,  on  removing  the 
bowls,  and  permitting  the  bloody  sides  of  the  slides  to  remain 
downward,  until  all  the  ether  and  chloroform  had  evaporated, 
that  no  disintegration  or  marked  change  in  the  form  of  the 
corpuscles  was  observable  under  the  microscope,  on  comparing 
them  with  the  blood  of  a  frog  unaffected  by  an  anaesthetic. 
This  forcibly  demonstrates  the  difference  between  exposure  of 
the  blood  to  direct  contact  and  the  vapor  of  chloroform  or  ether, 
even  out  of  the  body. 

Third  Series. — Over  and  again,  in  the  presence  of  a  number 
of  gentlemen,  we  have  placed  frogs  under  the  influence  of  ether, 
chloroform  and  nitrous  oxide,  and  examined  their  blood- 
corpuscles  immediately  after,  without  finding  any  disintegration 
or  change  in  the  form  of  the  corpuscle.  In  one  instance,  a 
frog  was  so  completely  narcotized  by  chloroform  that  it  died  ; 
the  thorax  of  the  animal  was  opened,  the  lungs  cut  out,  and 
the  blood  obtained  directly  from  that  organ,  and  even  here, 
where,  if  the  inference  of  an  altered  blood  was  correct,  there 
should  have  been  discharge  of  nuclei,  disintegration,  or  marked 
change  in  the  form  of  the  corpuscle,  nothing  of  the  kind  was 
evident,  as  will  be  seen  by  the 
accompanying  illustration, 
drawn  from  the  slide  on  which, 
the  blood  was  placed.  (Plate  16.) 
As  already  intimated,  the  ex- 
periments in  this  direction  have 
been  prosecuted  on  every  avail- 
able occasion  within  the  past 
few  months ;  and  we  have  not 
confined  our  experiments  to 
frogs,  but,  in  the  course  of  vivi- 
sections on  a  large  number  of 

animals    (rabbits,  dogs,  cats  and    Corpuscles  from  the  luDgsofa  frog  which 
,,.,,,,  .  died  under  the  influence  of  chloroform. 

pigeons),  to  illustrate  our  win- 
ter course  of  lectures  on  physiology,  when  these  animals  have 


Plate  16. 


148 


ARTIFICIAL  AN.T3STHESIA. 


Plate  17. 


been  placed  under  the  influence  of  ether  or  chloroform,  their 
blood  has  been  examined,  and  no  change  in  the  form  of  the 
corpuscle  has  been  evident. 

Fourth  Series. — The  examination  of  the  blood  of  a  number 
of  human  beings,  drawn  prior  to,  and  after  having  been  under 
the  influence  of  ether,  chloroform  or  nitrous  oxide,  has  yielded 

similar  results,  as  will  be  evident 
from  the  accompanying  illus- 
tration of  the  blood,  obtained 
from  a  patient  (Plate  17)  while 
under  the  influence  of  chloro- 
form. Any  one  accustomed  to 
microscopical  examinations  will 
recognize  the  normal  character 
of  the  corpuscles,  so  far  as  it  is 
possible  to  present  them  in  a 
woodcut. 

In  conclusion,  although  it  is 
not  our  intention  in  this  com- 
munication to  engage  in  an 
extended  inquiry,  relative  to  how  anresthetics  produced  their 
effects,  it  seems  to  us  that  the  above  experiments  demonstrate 
that  we  are  not  warranted  in  denying  that  these  agents  act 
directly  upon  the  nerve  centres.  All  the  phenomena,  indeed, 
attendant  upon  their  administration,  the  gradual  exaltation  of 
the  cerebral  functions,  followed  by  the  progressive  impairment 
and  temporary  suspension  of  the  special  senses,  the  loss  of  co- 
ordination on  the  part  of  the  cerebellum,  and  when  the  agent 
is  pushed  too  far,  the  arrest  of  respiration  and  circulation 
through  the  decided  impression  made  upon  the  medulla  oblon- 
gata, seem  to  favor  this  hypothesis,  in  contradistinction  to  the 
theory  that  anassthesia  is  due  to  suspension  of  oxygenation. 
In  1877,  there  was  another  series  of 

Experiments  with  Nitrous  Oxide,  by  the  late  Dr.  McQuiIlen,and 
Doctors  J.D.  Thomas  and  Tarnbull. — December,  1877. — A  large- 
sized  frog  was  placed  under  a  glass  jar  holding  five  quarts  of 
pure  nitrous  oxide,  and  kept  there  sixteen  minutes.  With  the 
exception  of  some  change  in  the  color  of  the  skin,  there  was  no 


Corpusclea  of  a  patient  under  the  in- 
fluence of  chloroform. 


FOUETH   SEEIES   OF   EXPERIMENTS.  149 

apparent  impression  made  the  first  five  minutes,  as  he  jumped 
about  when  the  jar  was  moved  in  the  pneumatic  trough.  After 
that  he  assumed  the  position  of  sitting  on  the  bottom  of  the  jar, 
and  maintained  it  until  removed  from  the  jar,  when  he  was 
found  in  a  semi-torpid  state,  with  the  eyes  wide  open.  On 
touching  the  eyes  gently,  the  lids  closed,  and  then  opened 
immediately,  and  the  leg  retracted  on  pricking.  Two  minutes 
after  removal  from  the  jar,  he  moved  slowly  about  the  floor, 
and  ten  minutes  later,  he  hopped  from  a  table  on  to  the  floor. 

After  remaining  out  for  thirty-five  minutes,  he  was  again 
placed  under  the  jar,  in  a  fresh  supply  of  gas  and  kept  there 
for  thirty  minutes ;  on  being  removed  he  presented  the  same 
semi-torpid  condition,  and  recovered  from  it  in  two  minutes. 
In  twenty  minutes,  he  was  a  third  time  placed  in  fresh  nitrous 
oxide,  and  remained  there  fifteen  minutes,  with  the  same  result 
as  the  previous  trials  ;  the  confinement  for  one  hour,  in  all,  to 
the  influence  of  nitrous  oxide,  not  having  made  any  marked 
impression  on  him.  Examined  under  one-fifth  objective,  and  B, 
eye-piece,  the  blood-corpuscles  presented  no  disintegrative  dis- 
charge of  nuclei  or  change  of  form. 

A  small-sized  rabbit  was  kept  under  the  influence  of  nitrous 
oxide  for  two  minutes,  and  in  one  minute  after,  was  completely 
restored  to  consciousness.  He  was  then  kept  under  the  gas 
for  five  minutes  consecutively  and  recovered  in  one  and  a  half 
minutes.  After  this,  for  twenty  minutes,  ofi"  and  on,  the  animal 
was  under  the  influence  of  the  gas.  In  three  minutes  after  re- 
moval from  it,  he  was  running  around  the  room  as  though 
nothing  had  occurred.  The  blood  examined  under  the  micro- 
scope gave  no  evidence  of  disintegration  of  the  blood  corpus- 
cles. "  There  is  reason*  to  conclude  that  the  inhalation  of  either 
nitrous  oxide  or  nitrogen,  causes  an  accumulation  of  carbonic 
acid  in  the  blood.  To  produce  oxidation  of  the  brain,  there  must 
be  (1)  a  free  current  of  blood  through  the  capillaries  of  the 
brain  ;  (2)  the  blood  must  be  duly  aerated  or  oxygenized  ;  (3) 
the  blood  must  be  unmixed  with  any  material  which  prevents 
or  impedes  the  giving  up  of  oxygen  from  the  blood  to  tissues." 

*  As  well  observed  by  Buxton :  "  But  whatever  union  does  take  place,  It  is  very 
unstable,  as  blood  parts  at  once  with  nitrous  oxide  when  left  in  free  contact  with 
oxygen  or  air." 


150  ARTIFICIAL  ANAESTHESIA. 


Tlie  Spectroscope  and  its  Relations  to  Anaesthetics.* 

It  has  been  stated  that  "  Through  the  agency  of  the  spectro- 
scope, has  been  supplied,  the  missing  link  to  our  chain  of  rea- 
soning. The  shadoivy  Jield  of  theories  has  been  cleared  up,  the 
laws  governing  the  relations  of  anassthetics  in  contact  with  the 
blood  current,  have  been  ascertained,  and  rational  progress  has 
been  made  to  insure  safe  anxsthetics.  I  have  abiding  faith  in  the 
progress  of  chemical  science,  that  it  will  finally  point  out  an 
agent,  from  the  almost  inexhaustible  materials  at  its  command, 
that  will  satisfy  all  ends  of  surgical  requirements, — an  anaes- 
thetic that,  while  it  will  annihilate  temporarily  all  sensation, 
will  leave  consciousness  and  vitality  intact." 

We  shall  now  pass  to  the  article  on  nitrous  oxide  gas,  and 
let  our  readers  judge  for  themselves  of  the  rational  progress 
made,  and  the  clearing  up  of  theories  by  positive  experiments 
justifying  or  not,  the  condemnation  of  this,  the  only  anaes- 
thetic as  yet  discovered  which  possesses  such  a  wonderful 
record.  We  will  give  our  experiments  and  observations,  and 
while  quoting  from  others  in  regard  to  the  injurious  effects, 
have  not  withheld  any  of  all  the  well-authenticated  cases  of 
deaths  from  this  agent, 

"  It  has  been  demonstrated  by  Herrraan,  and  verified  by 
Hoppe  Seyler,  Gorup  Besanez  and  W.  Preyer,  that  nitrous 
oxide  gas  possesses  a  keen  affinity  for  oxodized  blood,  as  well 
as  for  artificial  oxy-haemato-crystalline  in  solution.  The  affin- 
ity is  so  strong,  that  when  a  current  of  this  gas  is  passed 
through  a  solution  saturated  with  carbonic  oxide  hsemato-crya- 
talline,  the  carbonic  oxide  is  driven  out  by  the  nitrous  oxide, 
which  takes  its  place,  volume  for  volume. 

"  When  a  current  of  nitrous  oxide  gas  is  forced  through  a 
slightly  alkaline  solution  of  haemato-crystalline,  the  solution 
loses  its  dichroism  and  assumes  a  slight  cormoisin  red  color. 
When  the  solution  is  placed  before  the  spectroscope,  we  ob- 

*The  Beauties  of  the  Spectroscope,  and  its  Halations  to  Anresthetics.  Proceedings 
of  Am.  Den.  Con.  and  Southern  Den.  Ass.  and  the  Den.  Ass.  of  Md.  Held  at  Oak- 
land, Garrett  County,  Md.,  August,  1877.    Baltimore:  Innes  &  Co.,  Printers. 


RELATIONS  OF  SPECTROSCOPE  TO  ANAESTHESIA.    151 

serve  that  in  proportion  aa  the  gas  exerts  its  influence,  the 
two  bands  betv/een  D,  and  E,  fade  away,  and  disappear  finally 
altogether ;  and  there  is  a  moment,  says  Preyer,  '  when  the 
spectrum  is  continuous.' 

"The  disappearance  of  these  blood-bands  means  here,  as 
it  means  in  other  instances,  disappearance  of  oxygen  from  the 
blood,  or  complete  deoxidation,  and  unless  a  fresh  supply  is 
speedily  furnished,  suffocation  must  ensue. 

"As  the  action  of  nitrous  oxide  gas  upon  the  blood  solution 
continues,  soon  after  the  fading  away  of  the  two  bands,  two 
new  bands  appear  resembling  the  oxy-blood  bands,  but  differ- 
ing from  them  in  position  and  depth  of  shading, — they  are 
paler  and  more  blurred  in  outlines. 

"I  before  told  you,  that  when  blood  is  simply  deprived  of 
its  oxygen,  the  blood  reduction  band  would  follow  the  disap- 
pearance of  the  two  oxidized  broad  bands,  and  that  then  the 
simple  contact  of  atmospheric  air,  with  such  deoxidized  blood 
solution,  would  suffice  to  cause  the  reappearance  of  the  two 
oxygen  blood-bands. 

"  But  we  see  here,  that  instead  of  Stokes'  band,  two  entirely 
new  bands  have  made  their  appearance,  and  when  the  blood, 
saturated  with  the  nitrous  oxide,  is  then  submitted  to  the 
action  of  reducing  agents,  the  broad  band  of  Stokes,  as  a  re- 
duction band,  can  no  longer  be  produced  at  all,  proving  that  a 
more  permanent  change  has  taken  place  in  the  vital  chemistry 
of  the  blood. 

"  When  a  current  of  nitrous  oxide  gas  is  passed  through  a  so- 
lution not  made  previously  alkaline,  stil!  further  change  takes 
place.  Here  aportionof  the  nitrous  oxide  gas  rapidly  oxidizes  at 
the  expense  of  the  oxygen  of  the  blood,  and  forms  hyponitric 
acid.  Preyer.  holds,  that  this  hyponitric  acid  unites  with  the 
hsemato-cryst  of  the  blood  in  its  nascent  state.  Like  all  acids, 
it  altera  and  suspends  the  coagulability  of  the  blood,  and 
initiates  other  important  chemical  and  optical  changes.  This 
event,  is  marked  by  the  appearance  of  an  absorption  in  red  to 
the  left  of  D,  from  the  53°  on  Preyer's  scales  towards  D,  and 
another  one  between  b,  and  F.  I  lovik  upon  the  appearance  of 
this  absorption  in  red,  as  an  indication  that  hyponitric  acid 


152  ARTIFICIAL  ANAESTHESIA. 

has  formed,  and  has  united  with  the  blood.  We  already 
learned  that  p.ll  acids,  cyanic  acid  excepted,  cause  a  decom- 
position of  the  blood,  and  its  product  is  hiBmatine. 

"  Now  let  U3  logically  apply  all  these  ascertained  facts  to 
our  case  in  hand,  in  order  to  learn  how  this  gas  produces  its 
effects  upon  the  economy. 

"  In  Pf eyer's  experiments,  we  have  seen  that  dogs,  when  per- 
mitted to  inhale  oxygen  at  the  highest  stage  of  the  dyspnea, 
become  rapidly,  as  well  as  ever.  Not  so  after  the  inhalation  of 
nitrous  oxide  gas.  A  certain  effect  upon  the  blood  has  taken 
place,  often  unimportant  and  transient,  at  other  times  more 
permanent  and  grave,  sufficient  at  times  to  endanger  life 
itself.  We  have  also  seen,  that  under  favorable  conditions, 
hyponitric  acid  is  formed,  which  causes  a  decompo^ition  of  the 
hjcmato-crystalline  into  hoematine, — a  substance  which  is  not 
capable  of  sustaining  life.  Thus,  we  are  forced  to  acknowledge, 
that  the  application  of  this  gas  is  far  from  being  safe  and 
harmless  ;  that  on  the  contrary  it  is  pregnant  with  grave  con- 
sequences. 

"Having  fully  pointed  out  to  you  the  manner  in  which 
nitrous  oxide  gas  affects  the  blood,  it  must  serve  you  as  a 
type  for  all  those  agents  which  deprive  the  blood  of  its  oxy- 
gen, and  form  stable  crystalline  compounds  with  the  haemato- 
crystalline,  whereby  its  life-function  is  gravely  impaired,  and 
under  certain  conditions  forever  lost. 

"In  case  of  accident  with  nitrous  oxide,  our  indications 
are  confined  to  narrow  limits.  We  must  try  to  economize 
the  still  intact  blood-corpuscles,  a)id  by  transfusion,  and  es- 
pecially by  artificial  respiration,  to  favor  a  full  and  long 
supply  of  oxygen  to  sustain  the  little  flame  of  life.  Elec- 
tricity may  be  used  to  keep  up  the  muscular  action  of  the 
heart  and  lungs.  We  may  thus  succeed  to  ozonize  the  accu- 
mulated nitrous  oxide,  and  to  eliminate  it  from  the  system. 
Porowsky,  has  thus  succeeded  in  some  almost  hopeless  cases 
of  poisoning  with  carbonic  oxide,  and  the  procedure  seems 
to  me  well  adapted  also  in  cases  of  poisoning  with  nitrous 
oxide  gas." 

Has  the  gentleman  proven  the  proposition  he  has  started 


EXPERIMENTS   WITH   THE  SPECTEOSCOPE.        153 

with?  We  think  not.  If  experiments  are  carefully  made, 
and  facts  proven,  we  are  bound  to  receive  thorse  facts,  but 
not  the  theories  in  which  he  states  that  nitrous  oxide  gas 
"  deprives  the  blood  of  its  oxygen,  and  enters  into  a  close 
combination  with  its  crystallizable  material ;  so  bound,  it 
disables  this  latter  to  absorb  oxygen  from  the  air,  or  to  sup- 
ply it  to  the  oxidizable  tissues  of  the  economy."  The  fol- 
lowing experiments  were  undertaken  to  prove  or  disprove 
the  results  Dr.  Waterman  describes,  as  being  obtained  by  the 
spectroscope. 

These  experiments  in  the  course  of  spectroscopic  studies  of 
the  blood  by  the  action  of  reagents,  were  made  by  the  writer 
and  the  late  Prof.  J.  G.  Richardson,  of  the  University  of  Penn- 
sylvania ;  Dr,  Wm.  M.  Hodges,  of  New  York  ;  and  the  author's 
son,  Dr.  C.  S.  Turnbull,  of  Philadelphia: 

Pigeon,  under  the  anaesthetic  influence  of  nitrous  oxide  gas. 
— Respiration,  thirty-eight ;  pulse — unable  to  count — from 
one  hundred  and  eighty-two  to  two  hundred  and  ten.  Was 
rendered  insensible  in  twenty  seconds,  and  had  quite  recovered 
in  one  minute. 

Babbit. — Blood  identical  with  human  blood  under  micro- 
spectroscope  previous  to  nitrous  oxide  administration.  Res- 
piration, one  hundred  and  thirty-eight;  pulse,  one  hundred 
and  sixty.  Was  affected  in  forty  seconds,  and  completely  in- 
sensible in  two  minutes.  All  heart  action  ceased  in  one  minute 
and  forty-five  seconds..  There  was  no  change  in  the  blood 
under  the  spectrum  after  death  ;  little  or  no  change  in  the 
brain,  perhaps  slightly  anaemic;  heart's  color  natural. 

Dr.  L.  Turnbull,  and  Dr.  J.  D.  Thomas,  took  the  gas  and 
went  fully  under  its  influence,  and  their  blood  showed  no 
change.  By  passing  nitrous  oxide  through  the  blood,  the 
death-line  spoken  of  was  barely  visible,  but  after  adding  sul- 
phide of  ammonium,  it  was  clearly  seen. 

From  the  above  we  may  conclude  that  the  amount  of  pure 
nitrous  oxide,  necessary  to  induce  anaesthesia  in  man,  by  in- 
halation, does  not  so  affect  the  blood  as  to  cause  any  alteration 
of  the  two  well-known  bands,  in  the  green  portion  of  the 
spectrum.   In  other  words,  that  the  micro-spectroscope  gives  no 


154  AETIFICIAL,  ANiESTHESIA. 

evidence  that  radical  change  in  the  haemato-crystalline  is  pro- 
duced by  the  inhalation  of  nitrous  oxide  gas. 

Additional  Facts  in  Reference  to  the  Physiolo^cal 
Action  of  Nitrons  Oxide. 

Some  valuable  facts  have  recently  been  brought  before  the 
profession  *  in  regard  to  this  anaesthetic  confirmatory  of  the 
views  which  we  have  before  published  in  our  work  as  early  as 
1878. 

Nitrous  Oxide  (a)  is  said  to  produce  a  state  "which  we  term  \\ 
ancesihesia — a  loss  of  sensation ;  ^ 

(b)  it  initiates  certain  emotional  states,  provoking  a  sensation 
of  exhilaration  and  well-being — in  fact,  it  plays  the  role  of  a 
stimulant ; 

(c)  it  gives  rise  to  modifications  of  the  respiratory,  and 

(d)  circulatory  systems ; 

(e)  and  provokes  marked  muscular  movements,  which  may 
be  roughly  classed  as  (i)  rigidity  or  contracture  and  (ii)  jacti-^ 
tations.  <y 

These  are,  speaking  broadly,  the  effects  of  nitrous  oxide  upon 
the  mammalian  organism,  and  in  attempting  to  explain  them, 
we  must  ascertain  their  relations  among  themselves. 

A  further  fact  is  that  Dr.  Buxton  has  observed,  and  his 
views  are  in  harmony  with  most  of  the  authorities  upon  the 
subject,  that  during  the  stage  immediately  anterior  to  the  loss 
of  consciousness,  persons  under  the  influence  of  nitrous  oxide, 
are  hypercestheiic. 

Nitrous  oxide  does  induce  hyperaesthesia  ;  the  cerebro-spinal 
axis — at  least  as  far  as  sensation  goes — is  the  seat  of  the  changes 
which  nitrous  oxide  induce,  and  which  culminate  in  the  com- 
plete abeyance  of  consciousness.  In  this  connection  he  draws 
attention  to  the  convenience  of  grouping  the  brain  phenomena, 
due  to  nitrous  oxide,  in  three  periods  :  the  period  before  uncon- 
sciousness, which  he  contends  is  the  hyperaesthetic  period,  the 

♦On  the  Physiological  Action  of  Nitrous  Oxide.  By  Dudley  W.  Buxton,  M.D., 
B.  8.  Lond.,  M.K.C.P.,  Administrator  of  Ansesthetics  in  University  College  Hospital, 
the  Hospital  for  Women,  Soho  Square,  and  the  Dental  Hospital  of  London,  etc.,  1886. 
Pamphlet,  pp.  22.    Harrison  &  Sons,  St.  Mark's  Lane,  London. 


OBJECTIONS  TO  HYPEROXYGENATION  THEORY.    155 

period  of  unconsciousness,  and  the  period  of  returning  con- 
sciousness, in  which  hallucinations  take  their  origin. 

(a)  The  nitrous  oxide  may  either  give  rise  toother  bodies  by- 
change  in  its  own  chemical  form  ;  or  (b)  Acting  purely  in  a 
mechanical  fashion,  it  may  upset  the  normal  equilibrium  of  the 
funciions  of  respiration,  and  so  give  rise  to  accumulation  of 
aerial  fluids  in  the  blood,  which  would  normally  be  excreted. 
(o)  It  may  act  per  se,  and  exercise  a  specific  action,  just  as 
strychnine  or  any  other  body. 

At  one  period  it  was  believed  that  nitrous  oxide  acted  as 
an  oxidizing  agent,  by  splitting  up  the  body  or  tissues  into 
oxygen  and  a  residuum  of  nitrogen  compounds,  and  hence 
came  into  vogue  the  Apnoeal  or  Hyperoxygenation  theory  of 
Colton.  In  support  of  this  theory,  Stilie,  and  Maisch,  urge  that 
venous  blood  is  arterialized  by  shaking  it  with  nitrous  oxide, 
that  phosphorus  burns  in  it,  and  that  seeds  germinate  under 
bell-jars  of  nitrous  oxide.  Zimmerman,  whose  paper  we  have 
not  been  able  to  consult,  is  pledged  by  Stilie  and  Maisch  to  the 
statement,  that  pigeons  and  rabbits  will  recover  after  being 
placed  in  the  gas  for  eight  hours.  Of  course,  were  such 
theories  true,  we  should  have  to  admit  that  nitrous  oxide  is  a 
respirable  gas.  In  1872,  Dr.  Frankland,  came  to  the  conclusion 
that  nitrous  oxide  was  not  decomposed  during  its  sojourn  in 
the  body,  basing  his  opinion  upon  analyses  made  of  air  ex- 
pired by  rabbits,  when  confined  in  an  atmosphere  of  mixed  air 
and  nitrous  oxide. 

Jolyet,  and  Blanche,  who  published  their  results  in  Brown- 
Sequard's  "  Archives  de  Physiologie,"  find  vegetables,  as  well 
as  animals,  die  incontinently  when  placed  in  an  atmosphere  of 
nitrous  oxide.  And  in  the  case  of  certain  seeds,  Dr.  Buxton 
has  failed  to  induce  germination  in  an  atmosphere  of  pure  ni- 
trous oxide.  Of  course  combustion  will  take  place  in  nitrous 
oxide,  provided  the  heat  be  sufficient  to  produce  "  the  mode  of 
motion  "  in  the  molecules  of  the  gas,  which  leads  to  their  disin- 
tegration ;  but  experiment  has  stiown  that  the  heat  of  the  blood 
is  insufficient  to  initiate  such  a  dissociation.  Bonwill's  sugges- 
tion of  rapid  breathing  to  produce  anaesthesia,  probably  acts 
rather  through  the  changes  it  produces  in  the  blood-pressure 


156  ARTIFICIAL   ANiESTHESIA, 

of  the  cerebral  circulation  or  nervoua  exhaustion,  than  by  dint 
of  hyperoxygenation.  When  an  animal  is  killed  by  nitrous 
oxide,  the  blood,  if  examined  within  two  minutes  after  death, 
gives  the  well-known  spectrum  of  reduced  hiemoglobin,  while 
the  muscles  give  the  corresponding  one  of  reduced  myohicmatin, 
but  not  during  the  antesthetic  stage.  Here  we  are  dealing, 
not  with  nitrous  oxide  blood  effects,  but  these  complicated  and 
probably  overridden  by  asphyxial  efl'ects.  Another  possible 
way  by  which  nitrous  oxide  may  be  introduced  into  the  organ- 
ism is  by  means  of  the  nitrites,  and  form  combinations  with  the 
coloring  matter  of  the  blood,  oxyhsemoglobin. 

Bernard,  whose  classical  work  on  asphyxia  gives  the  fullest 
account  of  that  condition,  speaks  of  three  forms  of  asphyxia: 

(1).  That  arising  from  inhalation  of  irrespirable  gases  which 
are  themselves  harmless.  To  this  class,  many  authorities  would 
relegate  nitrous  oxide. 

(2).  That  due  to  poisonous  vapors,  such  as  carbonic  monoxide, 
sulphuretted  hydrogen,  and 

(3).  Asphyxia  from  wanr  of  air,  such,  for  example,  as  would 
ensue  upon  the  ligature  of  the  trachea.  He  subsequently  points 
out,  with  justice,  that  asphyxia  resulting  from  inhalation  of  an 
indifferent  irrespirable  gas,  and  that  due  to  want  of  access  to 
air,  are  in  fact  one  and  the  same  condition. 

The  arterial  blood,  becoming  gradually  deoxidized  by  part- 
ing with  its  oxygen  to  the  tissues,  acts  upon  the  medulla  respi- 
ratory centres  ;  hence  follows  hyperapncea.  This,  in  the  case  of 
some  persons  subjected  to  experiments  by  Drs.  Burdon  San- 
derson, John  Murray  and  Mr.  J.  Smith  Turner  (who  caused 
them  to  respire  pure  nitrogen),  did  not  occur  for  about  two 
minutes  after  commencement  of  inhalation. 

The  Phenomena  of  the  so-called  Asphyxia  of  Nitrous 
Oxide  Narcosis. — In  the  first  place  we  find  a  tolerably  uniform 
increase  in  the  number  and  depth  of  respirations.  Dr.  Buxton 
has  not  yet  succeeded  in  detecting  any  excess  of  expiratory,  over 
inspiratory  movements.  The  respirations  are,  more  correctly 
speaking,  simply  an  exaggeration  of  the  normal,  quite  regular, 
but  hurried  in  rhythm,  and  increased  in  depth.  This  begins 
certainly  within  half  a  minute — usually  within  fifteen  seconds — 


NITEOUS  OXIDE   NARCOSIS.  157 

from  the  commencement  of  nitrous  oxide  inhalation.  The  res- 
pirations, however,  become  slower  as  narcosis  proceeds,  and 
finally  stertor  supervenes,  which  frequently  is  followed  by  aperiod 
of  complete  respiratory  calm,  no  thoracic  movements  appearing. 
A  few  seconds  more,  and  respirations  are  recommenced,  and 
the  person  passes  quietly  into  ordinary  breathing.  He  has 
never  observed  anything,  which  in  the  slightest  degree 
resembles  the  expiratory  convulsions  one  is  so  familiar 
with,  in  the  case  of  the  lower  animals  killed  by  asphyxia. 
These  results  will  go  to  strengthen  the  present  theory,  that 
nitrous  oxide,  pushed  to  the  extent  of  narcosis,  does  not  give 
rise  to  circulatory  changes,  at  all  comparable  to  those  occurring 
in  the  course  of  asphyxia.  The  results  obtained  by  the  cardio- 
graph in  the  human  subject,  have  not  been  encouraging,  and 
Dr.  Buxton  is  determined  to  investigate  the  exposed  hearts 
of  mammals,  as  likely  to  render  a  more  reliable  record.  In 
this  connection,  the  experiments  of  Amory,  Krishaber,  Gold- 
stein and  Kuntz,  are  of  interest.  These  observers  found,  that 
animals,  when  subjected  to  the  vapors  of  nitrous  oxide,  after  a. 
time  died.  Now  it  is  important  to  notice  that  the  animals, 
when  made  the  subject  of  a  post-mortem  examination,  revealed 
the  usual  signs  of  asphyxial  poisoning.  But  this  is,  of  course, 
wholly  different  from  death  from  nitrous  oxide.  In  these 
animals,  nitrous  oxide  narcosis  was  followed  by  suffocation,  air 
was  excluded,  and  hence  asphyxia  ensued.  It  has  happened 
to  skilled  ansesthetists,  to  have  a  necessity  of  maintaining  ni- 
trous oxide  narcosis,  for  a  considerable  time.  This  has  been 
done,  by  allowing  the  patient  to  respire  air  at  long  intervals. 
In  this  way  a  really  prolonged  narcosis  can  be  effected,  while 
we  are  seeking  only  to  promote  the  action  of  nitrous  oxide 
upon  the  nervous  centres. 

The  true  test,  and  one  of  great  value,  is  the  examination  of 
the  blood  shed  during  anaesthesia,  performed  by  the  writer  in 
conjunction  with  the  late  Professors  McQuillen,  Eichardson 
and  Turnbull,  gas  being  administered  by  Dr.  Thomas.  We 
may  then  conclude  that  nitrous  oxide  produces  narcosis,  by 
virtue  of  other  than  asphyxiating  qualities. 

This  gas,  then,  enters  the  blood  through  the  lungs  and  ex- 


158  ARTIFICIAL  ANESTHESIA. 

ercisea  a  certain  specific  action  upon  the  nervous  centres. 
And  here  we  liave  a  ready  explanation  of  an  otlierwise  most 
anomalous  circumstance,  viz. :  that  in  a  certain  number  of 
cases,  persons  evince  the  utmost  toleration  of  nitrous  oxide, 
and  resist  the  nepenthal  action  for  a  minute  or  more.  Were 
nitrous  oxide  purely  an  asphyxiant,  we  should  invariably  nar- 
cotize our  patients  when  replaced  by  oxygen,  but  such  is  not  the 
case — in  fact,  they  are  narcotized  before  this  oxygen  is  exhausted. 

Nitrous  oxide  enters  the  blood  by  producing  aniBsthesia 
with  no  combinations  with  either  the  oxyhtemoglobin  or  the 
globulins,  unless  it  is  employed  without  air.  It  then  passes  to 
the  perve  centres  as  venous  blood,  plus  some  stimulating  and 
narcotic  influence,  and  gives  rise  to  subjective  exhilaration. 
Upon  the  heart  it  acts  as  an  accelerator.  At  this  time  the  in- 
hibitory centres  are  in  a  state  of  at  least  lessened  activity,  as  is 
evidenced  by  involuntary  movements,  micturition,  etc. ;  later 
the  reflexes  are  lost.  During  this  stage  the  blood-pres?!ure 
would  appear  to  be  lessened,  the  action  of  the  heart  accelerated 
and  the  respiratory  rhythm,  at  first  quickened,  subsequently 
slowed  to  a  standstill.  This  state  of  things  persists  for  a  while, 
and  is  accompanied  by  relaxation  of  some  muscles,  e.  g.,  the 
palatine  and  faucal  muscles,  while  other  muscles  are  the  seat 
of  arhythmic  clonic  and  tonic  contractions.  Following  upon 
this  stage  we  usually  meet  with  the  phenomena  of  recovery. 
During  the  period  of  recovery  a  further  stage  of  excitement 
appears,  and  it  is  commonly  associated  with  hallucinations — 
sometimes  pleasant,  sometimes  extravagant.  The  sense  soon 
becomes  keenly  upon  the  alert — and  operative  measures  pro- 
longed into  this  period  give  rise  to  the  most  intense  pain. 
Patients  will  declare  the  pain  in  such  cases  transcends  that 
where  no  gas  is  given. 

In  a  preliminary  communication  made  before  the  Odontolog- 
ical  Society,  Dr.  Buxton  attempted  to  review  some  of  the  more 
authoritative  views  which  have  from  time  to  time  been  advanced 
with  regard  to  the  physiological  action  of  nitrous  oxide  upon 
the  organism.  It  remains  to  consider  the  evidence  which  ex- 
perimental research  has  placed  in  our  hands,  and  to  attempt  as 
briefly  as  may  be  to  formulate  what  conclusions  are  warranted 


THE   SPECTROSCOPE   AND   NITROUS  OXIDE.        159 

by  the  results  of  such  researches;  and  further,  to  adduce  from 
these  conclusions,  practical  rules  such  as  may  guide  in  the  em- 
ployment of  nitrous  oxide  gas  as  an  anseslhetizing  agent. 

Eesearches  made  by  means  of  the  spectroscope  upon  blood 
when  it  is  impregnated  with  nitrous  oxide,  do  not,  at  least, 
aflbrd  evidence  of  value.  MacMunn,  whom  Dr.  Buxton  before 
quoted,  failed  to  obtain  any  characteristic  spectrum  from  the 
blood  of  animals  poisoned  with  nitrous  oxide.  He  repeatedly 
made  the  attempt  to  obtain  a  spectrum  peculiar  to  this  agent, 
but  was  also  unsuccessful,  the  only  bands  discernible  being 
the  broad  one  between  Fraunhofer's  D  and  E  lines,  which  of 
course  merely  represents  the  spectrum  of  reduced  hsemoglobin. 
Dr.  Halliburton,  Assistant  Professor  of  Physiology  in  Univer- 
sity College,  was  good  enough  to  examine  some  blood  for  Dr. 
Buxton,  and  he  concurs  in  the  results  given  above.  Thtse 
confirm  our  own  experiments  and  observations. 

It  appeared  evident  that  nitrous  oxide  gas  exerted  a  very 
considerable  effect  upon  the  nervous  system  (see  experiments 
of  Amory),  and  Dr.  Buxton  was  anxious  to  undertake  experi- 
ments in  the  direction  of  the  ascertainment,  whether  or  not  it 
produced  physical  changes  in  the  condition  of  the  brain.  One 
way  in  which  it  was  possible  to  investigate  this  point  was  to 
examine  the  actual  changes,  if  any,  in  the  brain  whilst  the 
animal  was  placed  under  nitrous  oxide. 

Accordingly  the  experiments  were  made,  by  the  kindness  of 
Professor  Victor  Horsley,  at  the  Brown  Institution,  London. 

The  skull  of  a  medium-sized  dog  was  trephined,  and  nitrous 
oxide  gas  given  through  a  tracheal  tube  fitted  with  a  very 
freely-acting  expiration  valve.  The  trephine  hole  exposed  the 
outer  third  of  the  sigmoid  gyrus  on  the  right  side.  Under  nor- 
mal conditions  the  brain  was  seen  some  measurable  distance 
beneath  the  bone,  pulsating  quietly  and  synchronously  with 
the  respiration.  The  color  of  the  brain  covered  with  pia  mater 
was  pinky-red,  or,  more  exactly,  vermilion. 

As  soon  as  the  animal  began  to  breathe  nitrous  oxide,  the 
respiratory  rhythm  being  interfered  with,  the  brain  pulsations 
became  more  notable  and  somewhat  hurried.  When  the  gas 
was  pushed,  and  the  animal  made  to  take    it  in  freely,  the 


IGO  ARTIFICIAL  ANiESTHESIA. 

brain  substance  was  seen  to  awell  up  and  gradually  reach  the 
trephine  hole.  The  color  now  began  to  change,  and  a  dark, 
blue-red  shade  appeared  to  creep  over  the  exposed  brain, 
robbing  the  brightness  of  the  vermilion  and  replacing  it 
by  a  laky  purple.  The  brain  undulations  were  at  this  stage, 
found  to  lessen  in  frequency  and  amplitude.  The  brain  sub- 
stance still  increased  in  volume,  and  even  protruded  without 
the  trephine  hole,  almost  motionless,  and  of  a  pearly,  glisten- 
ing lustre  of  bluish  hue.  The  vessels,  examined  with  a  strong 
lens,  presented  the  well-known  look  of  commencing  stasis. 
At  this  stage  the  nitrous  oxide  was  stopped  and  the  animal 
allowed  to  inspire  air  freely.  Quietly  and  gradually  with 
each  successive  breath  of  air  the  brain  receded,  the  undula- 
tions returning,  and  resuming  their  normal  rhythm  and  range. 
With  these  changes  came  a  return  of  the  vermilion  tinge 
which  characterizes  the  healthy  brain  substance.  This  experi- 
ment was  repeated ;  in  some  cases  the  animal  was  anaesthetized 
by  means  of  a  face-piece  with  an  expiration  valve,  and  in  others 
a  tracheal  tube  was  introduced,  but  the  phenomena  observed 
were  strikingly  uniform.  It  was  next  determined  to  conduct  a 
control  experiment,  first  pushing  the  nitrous  oxide  to  the  verge 
of  death,  and  subsequently  producing  asphyxia  by  deprivation 
of  all  air. 

In  the  experiment  in  which  nitrous  oxide  was  given,  the 
brain  being  exposed  as  in  the  last  research,  the  gas  was  pushed 
until  respiratory  movements  completely  ceased.  In  a  little 
over  a  minute  (1  min.  10  sees.)  the  brain  substance  had  become 
livid  and  swollen  to  above  the  calvarial  edge ;  the  animal  was 
absolutely  insensitive  to  painful  sensation;  his  limbs  showed 
marked  jactitations.  In  about  1  min.  30  sees,  normal  respira- 
tory movements  had  ceased.  Artificial  respiration  was  prompt- 
ly resorted  to,  and  speedily  the  natural  thoracic  movements 
were  resumed.  The  trachea  was  then  occluded  and  the  brain 
observed.  In  about  a  minute  the  brain  substance  assumed  a 
deep  purple  dull  hue,  which  in  another  half-minute  became 
very  intense  ;  the  brain  then  began  to  recede,  sinking  deeply 
from  the  trephine  hole.  In  two  minutes  the  sphincters  became 
relaxed  and  further  sinking  of  the  brain  took  place.     In  three 


EFFECT  ON  THE  BRAIN  AND  SPINAL  COKD.        161 

minutes  the  respiratory  movements  were  very  profoundly  inter- 
fered with,  only  manifesting  themselves  by  long-drawn  gasps 
which  were  separated  by  long  intervals.  In  five  minutes,  al- 
though all  respiratory  movements  had  ceased,  the  heart  still 
beat.  In  SIX  minutes  access  of  air  was  allowed,  but  artificial 
respiration  failed  to  effect  recovery. 

These  experiments  appear  peculiarly  instructive,  firstly,  as 
showing  in  a  very  marked  way  the  difference  between  the 
brain  condition  when  fed  with  nitrous  oxide-laden  blood,  and 
when  supplied  with  deoxidized  blood  containing  tissue  refupe; 
and  secondly,  when  viewed  in  relation  with  the  clinical  phe- 
nomena of  nitrous  oxide  narcosis.  As  Dr.  Buxton  pointed  out 
in  his  last  communication  to  the  Society,  there  is  a  zone 
of  bypersesthesia  which  separates  the  normal  consciousness 
from  the  absolute  loss  of  sensation  on  the  one  hand,  snd  on 
the  other  which  unites  the  stage  of  oblivion,  or  sleep,  with  the 
return  to  full  mental  activity.  It  is  presumably  at  this  epoch 
that  the  dreams  of  mental  exaltation  and  physical  joy  occur, 
and  it  is  then  that  slight  external  physical  stimuli — e.  g.,  a 
flash  of  light,  a  noise,  a  movement — will  become  a  thousandfold 
magnified  and  perverted  in  the  patient's  brain.  The  peculiar 
filling  of  the  brain  would  seem  to  offer  a  physical  counterpart 
for  these  mental  conditions,  and  apparently  so  rapidly  modifies 
the  brain  cells  that  they  are  incapable  of  further  reception  or 
ideation :  an  initial  increased  exaltation  gives  way  to  a  com- 
plete abeyance  of  function. 

Experiments  in  the  same  lines  were  also  made  with  regard 
to  the  action  of  nitrous  oxide  upon  the  spinal  cord.*  The 
animal  being  under  the  influence  of  chloroform  and  curare,  the 
laminae  of  the  lower  dorsal  and  lumbar  vertebrae  were  removed 
and  the  cord  exposed  lying  in  the  spinal  canal.  The  animal 
was  then  made  to  respire  nitrous  oxide,  only  expiring  through 
a  slit  in  the  canula.  A  very  marked  effect  soon  showed  itself: 
the  cord  gradually  enlarged  and  cerebro-spinal  fluid  began  to 
well  out,  showing  the  enlargement  of  the  whole  length  of  the 

*  These  experiments  were  made  at  the  University  College  Physiological  Laboratory, 
and  Dr.  Buxton  was  indebted  to  Mr.  John  Rose  Bradford,  B.Sc,  for  their  executiou 
and  to  Professor  Schafer  for  the  use  of  the  Laboratory. 


162  ARTIFICIAL   ANESTHESIA. 

cord.  This  experiment  was  repeated,  and  the  same  result  was 
always  obtained.  However,  as  will  readily  occur  to  you,  two 
causes  might  have  conceivably  produced  this  eft'ect,  namely — 
(1)  the  exclusion  of  oxygen,  i.e.,  the  asphyxia,  or  (2)  the  pres- 
ence of  nitrous  oxide.  To  test  which  of  these  possible  factors 
was  really  responsible  for  the  swelling  up  of  the  cord,  the  ani- 
mal was  deprived  of  air,  and  no  nitrous  oxide  given.  At  first 
the  cord  remained  unchanged — at  least  no  swelling  took  place, 
and  no  escape  of  cerebro-spinal  fluid  occurred.  Soon,  however, 
as  the  blood  became  more  and  more  deoxygenized,  the  cord 
grew  smaller,  shrinking  below  its  former  level  in  the  spinal 
canal.  There  was  no  doubt  but  that  while  in  nitrous  oxide 
administration  the  cord,  like  the  brain,  grew  larger,  in  asphyxia 
it  shrank.  To  test  this  effect  further,  the  following  crucial  ex- 
periment was  tried.  The  animal  was  subjected  to  asphyxia, 
and  the  cord  was  watched  until  it  had  perceptibly  shrunk,  when 
nitrous  oxide  was  allowed  to  enter  the  lungs.  If,  as  we  assumed, 
nitrous  oxide  was  capable  of  dilating  the  vessels  of  the  cord 
when  acting  upon  them  in  a  normal  condition,  it  was  thought 
that  it  should  produce  a  like  effect  when  the  cord  vessels  were 
contracted  by  asphyxia.  The  experiment  confirmed  this  sup- 
position, for  as  soon  as  the  animal  had  its  lungs  well  saturated 
with  nitrous  oxide,  the  cord  was  seen  to  expand  and  the  cere- 
bro-spinal fluid  began  to  escape. 

We  may  now  briefly  consider  the  conclusions  these  experiments 
upon  the  brain  and  spinal  cord  appear  to  justify.  In  brain  and 
cord  alike,  we  meet  with  dilatation  of  the  vessels,  with  of  course 
an  increased  blood  supi)ly  to  the  nerve  centres.  Such  a  condi- 
tion would  be  favorable  to  the  dissociation  of  nervous  energy,  but 
this  would  soon  be  followed  by  over-distension  and  interference 
with  due  regularity  of  the  cerebral  and  cerebellar  circulation  sub- 
versive of  ideation  and  the  performance  of  adjusted  muscular  ac- 
tion. The  interference  to  the  cord  circulation  must  also  interfere 
with  the  due  conduction  along  its  paths  as  well  as  with  the  cor- 
relation between  its  parts  and  the  higher  brain  centre^^.  At  pre- 
sent we  may  not  be  in  a  position  to  theorize  beyond  the  broad 
general  statements  given  above,  but  Dr.  Buxton  thinks  we  may 
justly  recognize  in  the  interference  with  the  circulation  of  the 


NERVOUS  SYMPTOMS  FROM  NITROUS  OXIDE.      163 

brain  and  spinal  cord,  produced  by  the  inhalation  of  nitrous 
oxide,  a  phenomenon  which  accounts  for  not  only  the  every-day 
experience  we  meet  with  in  giving  the  gas  to  human  beings,  but 
also  to  those  aberrant  cases  which  occur  more  rarely,  and  evince 
marked  nervous  exhaustion  or  irregular  outbursts  of  nervous 
energy.     But  of  these  states  we  will  speak  again. 

The  development  of  nervous  symptoms  certainly  varies 
largely  with  the  initial  state  of  the  nerve  protoplasm,  for 
w^hile  in  some  persons  nitrous  oxide  induces  marked  nerve 
disturbance,  in  others  it  brings  about  none  whatever.  Dr. 
Buxton  introduces  a  brief  note  upon  ankle  clonus  as  re- 
vealed under  nitrous  oxide.  This  phenomenon  is  in  a  certain 
percentage  of  cases  produced  when  the  patient  is  deeply  under 
the  gas. 

Among  reflexes  it  is  usual  to  consider  two  classes,  skin  or 
superficial  reflexes,  of  which  a  familiar  example  is  found  in  the 
conjunctival  reflex,  and  deep,  of  which  we  have  examples  in 
ankle  clonus  and  the  patellar  jerk  and  front  tap  reaction.  In 
health,  and  under  normal  functional  conditions,  the  superficial 
and  the  patellar  reflex  are  present;  certain  pathological  condi- 
tions lessen  or  exaggerate  these  reflexes,  and  cause  the  devel- 
opment of  ankle  clonus.  The  presence  of  ankle  clonus  points 
always  to  disease  or  functional  derangement  of  the  spinal  cord. 
Now  nitrous  oxide  produces  very  marked  derangement  of  the 
reflexes.  In  October,  1883,  Professor  Horsley*  drew  attention 
to  the  persistence  of  the  patellar  phenomena  under  profound 
anassthesia,  and  long  after  the  disappearance  of  the  superficial 
reflexes.  Clonus  has  been  found  to  be  developed  in  a  number  of 
cases,  although  it  is  not  a  constant  phenomenon  of  nitrous  oxide 
narcosis ;  hence  this  gas  not  only  abrogates  the  function  of  the 
brain  centres,  but  also  produces  marked  disturbance  in  the  cord, 
while  it  blunts  or  obliterates  peripheral  sense.  What  the  exact 
nature  of  this  derangement  of  the  cord  function  is,  we  cannot 
venture  at  present  to  ofier  an  opinion;  we  can  only  study 
it  by  means  of  the  phenomena  it  reveals.  These  also  are  va- 
rious, differing,  it  would  appear,  according  to  the  stability  of 

*  "  Brain,"  vol.  y1.,  p.  369  et  seg. 


164  ARTIFICIAL   ANESTHESIA. 

the  nervous  centres  of  the  individual  subjected  to  observation. 
Nor  is  this  surprising  when  we  remember  that  the  effects  are 
very  transitory,  and  must  be  largely  intluenced  by  collateral 
circumstances.  The  more  constant  cord  phenomena  are — 
rigidity  of  the  muscles,  which  passes  into  complete  flaccidity ; 
jactitations  which  appear  rhythmic  and  general ;  loss  of  super- 
ficial reflexes ;  persistence  of  knee  jerk.  Among  the  occasional 
phenomena  we  may  reckon — ankle  clonus;  opisthotonus  and 
emprosthotonus ;  paralysis  of  the  bladder  and  defsecation  centres, 
and  involuntary  and  unconscious  passage  of  urine  and  fteces  ; 
probably,  excitation  of  the  sexual  centres,  and  abolition  of  the 
normal  checks  imposed  upon  the  production  of  orgasm.  Fur- 
ther, we  must  reckon  the  secondary  results  apparently  due  to  a 
more  lasting  cord  eflect,  as  seen  in  paresis  or  even  paraplegia 
following  nitrous  oxide  inhalation.  Many  of  these  phenomena 
are  confessedly  rare,  and  are  perhaps  only  elicited  in  nervous 
systems  predisposed  to  take  on  the  condition,  whatever  it  may 
be,  which  nitrous  oxide  induces.  In  some  respects  nitrous 
oxide  would  appear  to  hold  comparison  with  strychnine.  The 
rigidity,  with  the  occasional  liberation  of  irregular  and  disor- 
derly explosions  of  nerve  energy,  occur,  although  with  different 
degrees  of  persistence,  alike  with  one  and  the  other  drug.  This 
would  perhaps  give  a  clue,  and  suggest  that  under  nitrous  oxide 
the  higher  ideomotor  centres  lose  control,  the  resistances 
throughout  the  cord  are  lessened,  and  the  cells,  deprived  of  the 
normalrestraints  imposed  by  habitual  and  associated  action, 
tend  to  irregular  explosive  outbursts.  It  seems  at  least  probable 
that  under  nitrous  oxide  not  only  do  we  meet  with  a  stage  of 
preliminary  exaltation  of  function,  misdirected  indeed,  and  un- 
constrained by  judgment,  in  the  brain  centres,  exemplified  by 
the  stage  of  hypersesthesia  spoken  of  above,  but  that  in  the 
lower  cord  centres  we  recognize  a  similar  initial  heightening  of 
activity,  also  irregular  and  disorderly,  followed  by  cessation  of 
their  functionation.  Indeed,  Dr.  Buxton  ventures  to  think  the 
samesequenceof  events  happens  in  the  vital  centres,  and  that  this 
explains  much  of  what  follows  in  the  remarks  made  upon  blood 
pressure,  cardiac,  and  respiratory  rhythm.  But  although  we  may 
not  as  yet  go  far  enough  to  dogmatize  upon  what  is  the  nature  of 


HEART  FAILURE  FROM   NITROUS   OXIDE.         165 

this  action  upon  the  cerebro-spinal  axis,  yet  it  seems  coDsonant 
with  our  facts  to  regard  it  as  a  sedative,  which,  while  provoking 
an  initial  exaltation  of  function,  eventually  plunges  the  tissues 
into  a  sleep,  or  state  like  the  long  dose  of  hibernation.  Certain 
it  is  in  some  cases  one  meets  with  a  quiet  prolongation  of  ni- 
trous oxide  narcosis,  unaccompanied  by  the  wild  convulsions 
of  asphyxia,  when  the  breathing  absolutely  stops  while  the 
heart  still  beats  on.  In  this  state  presumably  the  cord  centres 
have  gradually  yielded,  and,  the  medulla  reached,  the  respira- 
tory centre  has  also  peacefully  ceased  from  work,  and  the  pa- 
tient is  entranced  alike  in  his  mental  and  vegetative  functions. 
In  these  cases  artificial  respiration,  conducted  for  one  or  two 
admissions  of  air,  restores  the  patient  to  animation,  and  all 
goes  well.  No  danger  is,  in  fact,  incurred  unless  the  anaes- 
thetist is  either  incompetent  or  negligent  of  his  solemn  charge. 
It  seems  hardly  worth  while  to  do  more  than  to  beg  you  to 
compare  mentally  these  phenomena  with  those  aflForded  when 
asphyxia  terminates  life.  To  contrast  what  has  just  been  de- 
scribed with  the  mental  activity  persisting  almost  to  the  last 
gasp,  the  purposeful  struggles,  the  wild,  chaotic  respiratory 
efforts,  the  frantic  writhings  of  the  voluntary  muscles,  and  at 
length  the  general  massive  convulsions  passing  into  a  false 
quiet,  marked  by  an  occassional  gathering  together  of  the  failing 
nervous  energy  to  effect  a  spasmodic  explosion  of  muscular  force. 

Knowing  that  one  of  the  greatest  and  gravest  dangers  which 
besets  the  induction  of  anaesthesia  is  heart  failure,  it  becomes  a 
matter  of  very  great  importance  for  us  to  determine  the  be- 
havior of  nitrous  oxide  towards  the  heart  and  vascular  system 
in  general.  Dr.  Buxton's  and  our  own  investigations  in  this 
direction  have  been  made  to  ascertain  the  action  of  the  heart 
and  the  variations  of  blood  pressure  under  nitrous  oxide;  and 
further,  to  determine  how  far  the  variations  seen  when  nitrous 
oxide  was  exhibited  were  due  to  that  body,  and  how  far  to  the 
coincident  deprivation  of  oxygen. 

The  animals  selected  were  dogs  and  cats;  but  as  the  results 
were  practically  uniform,  it  is  unnecessary  to  particularize  the 
experiments.  Dr.  Buxton  dwells  on  his  great  indebtedness  to 
his  friends  Professor  Victor  Horsley,  Mr.  Bradford,  and  Pro- 


1G6  ARTIFICIAL  ANJESTHESIA. 

fessor  Scbafer,  through  whose  kindness  alone  the  research  was 
practicable. 

The  heart's  action  does  not  become  much  affected  under 
nitrous  oxide,  and  even  in  castas  in  which  that  gas  is  pushed 
until  complete  cessation  of  respiratory  movements  occurs,  the 
heartstill  continues  to  beat,  its  action  gradually  growing  weaker. 
In  no  case  have  we  seen  any  tumultuous  action  of  the  heart  or  a 
sudden  cessation,  only  the  gradual  sinking  to  rest  noticed  above. 
The  attempt  at  narcotizing  animals  and  timid  persons  produces 
a  temporary  acceleration  of  heart-beat,  but  as  soon  as  the  in- 
tellect becomes  under  the  influence  of  the  narcotic  this  accelera- 
tion passes  off  and  the  heart-beats  become  regular,  strong  and 
somewhat  slowed.  It  will  be  remembered  that  these  results  are 
in  accord  with  the  statements  already  published,  and  based 
upon  numerous  sphygmographic  tracings  taken  of  the  human 
radial  jmlse. 

The  blood  pressure  under  nitrous  oxide  inhalation  has  the 
following  peculiarities.  For  the  first  period  it  shows  little 
change;  but  subsequently  a  fall  of  pressure  takes  place.  Upon 
allowing  the  animal  to  inhale  air,  the  blood  pressure  recovered 
itself,  but  only  gradually,  and  by  passing  through  a  phase  of 
somewhat  irregular  curves.  •  These  curves  are  not  respiratory, 
as  they  take  place  even  when  the  animal  is  completely  paralyzed 
with  curare,  and  artificial  respiration  is  maintained.  In  some 
cases  a  slight,  but  very  slight,  rise  in  the  blood  pressure  took 
place,  but  a  rise  of  blood  pressure  which  persists  for  a  notable 
time  appears  always  to  follow  the  nitrous  oxide  inhalation. 
Control  experiments  were  conducted  to  test  the  effect  upon 
blood  pressure  when  the  animal  is  deprived  of  air.  These  were 
done  upon  curarized  animals  in  order  to  avoid  the  interference 
caused  by  dyspnceic  convulsions.  As  soon  as  the  air  supply  was 
cut  off,  the  blood  pressure  began  to  go  up,  and  rapidly  increased 
until  the  heart's  action,  which  lessened  in  force  pari  passu  with 
tJie  heightened  blood  pressure,  became  so  weak  that  it  was  ne- 
cessary to  allow  air  to  enter  the  lungs.  The  blood  pressure  then 
resumed  its  normal  height  very  quickly;  but  the  rise  which 
follows  after  nitrous  oxide  administration  does  not  appear  to 
ensue  after  asphyxia. 


BUXTON  REVIEWING    HIS  EXPERIMENTS.         167 

"  It  seems,  upon  reviewing  the  nitrous  oxide  experiments, 
and  controlling  them  by  the  asphyxia  experiments,  that 
nitrous  oxide  itself  has  no  very  marked  influence  upon  the 
heart  or  vessels  ;  that  what  action  it  has  is  to  steady  and  slow 
the  heart,  and  if  anything  to  strengthen  it,  and  that  the  action 
is  somewhat  prolonged.  The  vessels,  at  first  almost  unaffected, 
later  undergo  a  peripheral  dilatation  leading  to  a  lowering 
of  blood  pressure.  This,  however,  is  true  only  when  reserva- 
tion is  made;  for,  as  we  shall  see,  the  splanchnic  vascu- 
lar areas  are  contracted  at  first.  Upon  this  last  statement  I 
have  some  additional  evidence  to  offer.  A  good-sized  frog 
[Rana  temporaria)  was  placed  beneath  a  dome-shaped  glass 
vessel,  so  arranged  that  the  web  of  one  foot  was  outside  the 
vessel  and  could  be  examined  under  the  microscope.  The  dome 
was  emptied  of  air  and  kept  full  of  nitrous  oxide,  and  the  frog 
carefully  noted  while  the  web  was  examined.  It  was  necessary 
to  keep  the  whole  animal  in  nitrous  oxide,  as  cutaneous  respira- 
tion is  very  active  in  the  frog.  At  first  the  circulation  in  the 
web  was  found  to  be  slowed ;  at  the  same  time  the  minute  ves- 
sels were  seen  to  dilate,  and  this  slowing  and  dilatation  both 
became  more  marked  as  time  went  on.  Changes  also  appeared 
to  develop  in  the  corpuscles,  by  which  they  took  on  a  flattened, 
compressed  appearance.  At  length  the  respirations,  which  had 
become  slower  and  slower,  became  almost  extinguished,  the 
capillary  circulation  in  some  areas  was  almost  in  a  condition  of 
stasis,  whilst  throughout  the  field  extreme  slowing  had  occurred. 
At  this  point  the  frog  was  allowed  free  access  to  air,  and  at 
once  the  respiration  quickened,  the  blood-flow  increased  in  ra- 
pidity, becoming  many  times  more  rapid  than  under  the  gas. 
The  corpuscles  resumed  their  normal  aspect.  The  results  of 
such  experiments  upon  the  frog  point  to  a  peripheral  dilatation 
of  capillaries,  and  of  this  further  evidence  has  yet  to  be  ad- 
duced. It  needs  no  argument  to  show  that  a  vascular  viscus, 
like  either  the  kidney  or  the  spleen,  must,  under  variations  of 
blood  supply,  undergo  variations  in  size.  If,  therefore,  it  were 
possible  to  enclose  either  viscus  in  an  air-tight  receiver  com- 
municating with  an  oil  manometer,  it  would  give  indications 
of  increase  or  diminution  of  size  according  as  the  blood  supply 


168  ARTIFICIAL  ANAESTHESIA. 

were  increased  or  lessened.     Mr.  Bradford  has  kindly  enabled 
me  to  investigate  this  point  pretty  fully, 

"  The  experiments  made  upon  the  kidney  were  tolerably  nu- 
merous, and  were  singularly  uniform  in  their  results.  The  kid- 
ney in  an  animal  narcotized  with  nitrous  oxide  speedily 
undergoes  contraction,  which  corresponds  of  course  with  the 
contraction  of  the  renal  arteries.  This  contraction  continues 
as  long  as  the  nitrous  oxide  is  given,  but  as  soon  as  that  is  cut 
off  and  the  animal  respires  air  the  kidney  speedily  recovers  its 
normal  size,  but  no  dilatation  of  yes?els  beyond  normal  takes 
place.  With  this  condition  we  have  to  compare  the  behavior 
of  the  kidney  in  an  animal  subjected  to  asphyxia.  Here  the 
kidney  undergoes  a  dilatation  as  soon  as  air  is  cut  off.  This 
corresponds  with  dilatation  of  the  renal  arteries,  and  is  prob- 
ably due  to  increased  heart  action  called  into  being  by  the  ve- 
nosity  of  the  blood.  Later,  when  the  heart  fails,  the  kidney 
suddenly  contracts,  a  very  rapid  fall  in  the  kidney  curve  occur- 
ring. Thus  a  singularly  striking  contrast  in  the  behavior  of 
the  kidney  reveals  itself  according  as  that  viscus  is  influenced 
by  nitrous  oxide  or  asphyxia.  This  effect  upon  the  renal  cir- 
culation must  not  be  taken  as  militating  against  the  statements 
made  above  with  regard  to  the  general  blood  pressure  as  shown 
by  the  carotid  artery  and  about  the  circulation  in  the  brain  and 
cord.  It  is  well  known  that  certain  sedatives — morphine,  for 
example — dilate  the  vessels  in  one  area  while  they  contract 
those  of  other  areas. 

"  Passing  to  the  effects  produced  by  nitrous  oxide  upon  re- 
spiratory rhythm. 

"  The  chest  movement  will,  as  is  well  known,  continue  without 
any  air  entering  if  a  sufficiently  long  and  small  elastic  tube  be 
attached  to  the  tracheal  canula,  so  that  one  can  easily  compare 
asphyxia  with  nitrous  oxide  narcosis.  In  the  last  condition 
the  respirations  are  at  first  quickened,  but  not  lessened  in 
depth  ;  later  they  grow  slower  and  deeper,  and  still  later 
they  become  very  slow  and  somewhat  more  shallow ;  finally 
they  cease.  The  time  in  which  this  cessation  comes  about  var- 
ies considerably  in  animals.  I  have  not  seen  the  dyspnoeic 
struggles  under  nitrous  oxide  which  asphyxia  brings  about. 


DR.  Buxton's  conclusions.  169 

la  human  beings  I  have  seen,  especially  in  children,  complete 
cessation  of  respiration  without  the  slightest  preliminary  strug- 
gle. Alike  in  the  lower  animals  and  man  the  breathing  recom- 
mences if  pressure  is  made  on  the  chest.  These  changes  in 
respiration  are,  I  am  inclined  to  think,  due  wholly  to  the  action 
of  nitrous  oxide  upon  the  nerve  centres  presiding  over  respira- 
tion." 

In  conclusion,  there  are  various  practical  considerations 
which  Dr.  Buxton  and  the  writer  think  may  well  be  taken  into 
review  while  studying  the  physiology  of  nitrous  oxide  narcosis. 

If  nitrous  oxide  acts  as  a  sedative  in  virtue  of  its  own 
inherent  properties,  and  does  not  owe  its  value  as  an  anaes- 
thetic to  asphyxial  processes  called  into  play  by  concurrent 
privation  of  oxygen,  it  should  be  our  aim  to  push  the  gas 
and  give  free  vent  to  expired  gas.  We  should  see  that  our  pa- 
tient changes  as  freely  as  possible  his  residual  air  during  inspi- 
ration, and  expires  as  freely  as  possible  the  refuse-laden  nitrous 
oxide  which  has  been  stationary  within  the  air-spaces  during 
the  last  respiration.  We  cannot  but  think  that,  whatever  may  be 
the  saving  of  gas  brought  about  by  employing  supplemental 
bags  wherein  the  nitrous  oxide  is  collected  and  re-inspired 
again  and  again,  the  patient  suffers  by  their  use  from  the  double 
evil  of  breathing  diluted  and  impure  nitrous  oxide,  and  further, 
i:j  not  favorably  placed  for  exhaling  the  refuse  of  the  lungs.  We 
should  incline  to  attribute  to  this  method  the  cases  one  occa- 
sionally meets  with  of  severe  headache,  vertigo,  dizziness,  and 
other  untoward  symptoms  consecutive  upon  nitrous  oxide  in- 
halation. It  is  a  very  important  point  to  induce  very  free  in- 
spirations oi  pure  nitrous  oxide,  and  to  avoid  anything  like 
inducing  partial  asphyxia,  and  in  practice  this  gives  the  best 
and  the  most  satisfactory  results. 

The  behavior  of  the  heart,  under  nitrous  oxide,  should 
encourage  us  to  use  this  agent  freely,  and  during  its  admin- 
istration to  watch  rather  the  respiration  than  the  pulse;  since 
it  would  appear  that  syncope,  if  it  occurs,  occurs  secondarily 
through  the  lulling  to  sleepof  the  respiratory  centres.  The  cases 
in  which  nitrous  oxide  has  been  said  to  kill  by  heart  failure  are 
few,  and  even  in  these  we  are  not  at  all  sure  that  the  fatal  faint 


170  ARTIFICIAL   ANAESTHESIA. 

was  not  due  to  fear  or  shock  incurred  by  a  nervous  system  al- 
ready shaken  by  suffering,  and  rendered  still  more  obnoxious 
to  shock  by  an  imperfect  narcosis.  When  we  remember  the 
period  of  heightened  sensibility  which  precedes  complete  res- 
titution of  consciousness,  we  can  easily  comprehend  the  terrible 
jars  a  debilitated  nervous  system  must  sustain,  if  operative  pro- 
cedure be  carried  on  into  this  stage.  Clover  long  ago  pointed 
out  from  his  vast  clinical  experience,  that  patients  may  be  al- 
lowed to  cease  breathing,  and  yet  no  fear  need  be  entertained, 
as  a  few  vigorous  pressures  upon  the  thoracic  parietes  will  re- 
initiate respirations.  Now  we  accept  his  statement,  and  explain 
it  under  physiological  laws. 

There  are  other  practical  points  that  are  suggested  by  knowl- 
edge of  the  action  of  nitrous  oxide.  Of  these  not  the  least 
important,  is  that  the  erotism  called  into  existence  in  a  fairly 
large  proportion  of  patients,  and  controlled  only  in  a  few  by 
the  restraints  of  habitual  thought  and  judgment,  should  render 
all  persons  most  careful,  to  avoid  possible  incrimination  through 
hallucination.  For  the  sake  alike  of  patient  and  operator  a 
witness  should  always  be  within  earshot,  or  within  sight,  when- 
ever nitrous  oxide  is  administered. 

Again,  the  decided  action  this  antesthetic  has  upon  the  nerve 
centres,  and  its  tendency  to  call  forth  irregular  explosions  of 
nervous  energy,  might  by  some  be  taken  as  contra-indicatory  to 
its  employment  for  patients  who  are  the  subjects  of  epileptiform 
seizures.  We  do  not,  however,  think  we  can  with  justice  say,  that 
the  giving  the  gas  renders  a  fit  more  likely  to  occur  than  the 
operation.  We  are  aware  any  strong  excitant,  will  call  forth  a 
seizure,  whereas  the  sedative  action  of  the  nitrous  oxide  will, 
by  lessening  stimulation  from  without,  be  less  inclined  to  pro- 
voke the  attack. 

Conclusions. 

Nitrous  oxide  is  not  decomposed  in  the  blood,  nor  does  it  form 
a  chemical  combination  with  it.  Our  own  experiments  and 
those  of  others  have  proven  that  it  enters  the  blood  in  its  pure 
state,  and  is  eliminated  in  the  same  condition  by  the  skin,  kid- 
neys and  lung>',  with  only  a  diminution  in  quantity.    It  has  no 


EXPERIMENTS   AND   OBSERVATIONS.  171 

positive  poisonous  action  on  the  blood-corpuscles,  their  color 
not  being  in  the  least  altered  under  the  microscope,  nor  does  it 
cause  any  chemical  decomposition.  It  does  not  produce  death 
by  preventing  the  escape  of  carbonic  acid  gas,  for  if  the  expired 
air,  loaded  with  nitrous  oxide,  be  passed  into  lime-water,  a  car- 
bonate of  lime  is  precipitated. 

It  is,  however,  stated  by  some  observers  that  it  combines  with 
the  hsemaglobin,  and  this  is  said  to  be  proven  by  the  spectro- 
scope. 

After  numerous  experiments  and  observations  on  man  and 
animals,  we  have  arrived  at  the  following  conclusions  : 

1st.  Nitrous  oxide  gas  has  a  very  limited  range  when  given 
alone,  owing  to  the  rapidity  of  its  action  and  still  more  rapid 
elimination. 

2d.  It  acts  directly  upon  the  cerebrum  and  muscular  appa- 
ratus almost  simultaneously. 

3d.  It  produces  regular  and  progressive  modification  in  the 
action  of  the  heart  and  capillaries  of  the  skin,  and  if  carried 
to  a  greater  extent  it  affects  the  spinal  axis,  and  lastly  the  cere- 
bellum and  medulla  oblongata  with  suspension  of  respiration, 
circulation  and  finally,  death. 

4th.  Death  in  no  case  occurs  without  premonitory  symptoms, 
and  if  respiration  should  cease  for  even  a  half  to  one  minute, 
resuscitation  is  yet  possible. 

The  rapidity  of  the  pulse  is  generally  increased,  as  shown  by 
a  record  of  one  hundred  cases,  it  having  reached  as  high  as  one 
hundred  and  forty-four  in  one  case,  and  one  hundred  and 
twenty-eight  in  several  others.  In  a  few  there  was  little  or  no 
change. 


172  ARTIFICIAL   ANAESTHESIA. 


CHAPTER    XII. 

On  the  Safety  of  Nitrous  Oxide — Death  from  Nitrous  Oxiile — Thera- 
peutic Application  of  Nitrous  Oxide — Nitrous  Oxide  and  Oxygen 
as  an  Anfcsthetic  in  Labor — Clover's  Inhaler  for  Nitrous  Gas 
and  Ether — How  shall  Nitrous  Oxide  and  Ether  be  Administered  ? 
Drs.  Silk  and  Hewett — Death  from  Nitrous  Oxide  and  Ether 
— Inhaler  of  Codman  and  ShurtlefF  for  Nitrous  Oxide  and  Etber 
— Dr.  Thomas'  Nitrous  Oxide  Inhaler — Mixtures  of  Nitrous  Ox- 
ide, Ethers,  Chloroform  and  Alcohol  for  Inhalation — Oxygen, 
Nitrogen  and  Hydrogen  Gases  as  Ancesthetics. 

Nitrous  oxide  gas,  when  recently  prepared  and  free  from 
chlorine  or  nitric  oxide  gas,  is  one  of  the  safest  systemic 
anaesthetics  that  has  yet  been  discovered;  but  to  state  that  it 
is  absolutely  free  from  danger  would  not  be  true,  as  evidence, 
in  our  work  will  prove.  From  a  recent  letter  from  J.  D. 
Thomas,  graduate  in  dentistry,  of  long  experience,  devoted 
to  the  exclusive  administration  of  this  anaesthetic,  we  have 
the  following  statement:  "Philadelphia,  December  12,  1887. 
The  administration  of  nitrous  oxide  gas  in  my  hands  and 
those  of  my  assistant  has  now  reached  over  one  hundred  and 
fifty  thousand  (150,000)  persons."  When  you  take  into  consid- 
eration the  many  conditions  of  health  and  ill-health,  and  the 
various  phases  of  temperament  with  which  one  must  come  in 
contact  in  a  practice  such  as  his,  it  must  be  considered  re- 
markable that  this  great  number  of  people  could  be  taken,  in- 
discriminately, and  placed  under  an  anassthetic  without  fatality. 

The  success  attending  his  mode  of  administering  the  gas  can 
be  attributed  only  to  the  great  care  to  have  it  absolutely  pure 
and  fresh,  and  the  perfect  system  to  which  he  has  reduced  his 
method  of  operation. 

The  After-Eflfects  of  Mtroiis  Oxide  Gas. 

In  a  discussion  {Dental  Office  and  Laboratory,  July,  1885) 
on  a  paper  of  Dr.  J.  D.  Thomas',  on  Extraction  of  Teeth  with 
Nitrous  Oxide,  he  made  the  following  reply: 


BE.   THOMAS   ON   NITROUS   OXIDE.  173 

"  Di\  Guilford.  There  is  another  point  the  paper  did  not 
touch  on,  and  that  is  the  after-effects  upon  the  patient. 
The  society  would  be  glad  to  hear  from  Dr.  Thomas  or 
any  other  member  in  reference  to  it.  It  is  a  question  that 
has  been  largely  discussed  in  the  journals  at  different  times, 
more  so  formerly  than  at  present.  Cases  have  been  reported 
of  ill  effects  following  the  administration  of  the  gas,  but  in 
the  course  of  my  twenty  years'  practice  (part  of  it  in  a 
rural  village),  during  which  time  I  have  given  gas  several 
thousand  times,  I  have  never  known  of  any  evil  effects. 
Many  present  will  remember  that  both  Dr.  Barker  and  Dr. 
Webb,  while  living,  declared  that  they  felt  such  ill  effects 
in  their  own  persons. 

"  Dr.  Thomas.  From  experience  in  the  administering  of  ni- 
trous oxide  gas,  I  do  not  believe  there  is  any  ill  effect  whatever. 
I  have  never  known  any  which  could  be  traced  to  the  gas.  I 
have  had  probably  half  a  dozen  cases  where  people  have  made 
complaint  that  they  were  not  well  after  taking  it,  or  that  some 
serious  effect  had  taken  place  which  was  ascribed  to  the  gas, 
but  I  do  not  believe  that  such  was  the  case.  In  the  office  we 
do  not  have  a  patient  sick  at  the  stomach  once  in  six  months 
— and  then  it  will  be  such  a  person  as  will  sicken  at  the  sight 
of  blood — or  one  with  whom  any  nervous  excitement  will 
disturb  the  stomach  or  cause  him  to  faint.  There  is  another 
class  of  people,  whose  stomachs  become  disordered  from  long 
suffering,  with  a  loss  of  appetite  and  general  prostration.  I 
have  known  such  cases  where  sickness  has  followed,  sub- 
sequent to  the  extraction  of  the  teeth,  and  was  attributed  to 
the  effects  of  the  gas,  when  it  really  was  the  result  of  the 
previous  prostration  and  nervous  excitement,  or  a  severe 
bilious  attack,  which  culminated  after  the  operation. 

"  I  had  a  patient,  a  lady,  who  came  on  a  Tuesday  during  the 
heated  term  of  the  Centennial  year.  I  gave  her  gas  and  took 
her  tooth  out.  The  day  preceding,  her  menses  had  started. 
Oq  Thursday  night  her  mother  came  and  said  her  daughter 
was  in  a  terrible  state;  she  was  out  of  her  mind,  and  she  was 
sure  the  gas  was  the  cause  of  it.     At  first  I  thought  it  was  a 


1 74  artificial'  ANiESTIIESIA. 

case  where  the  gas  had  had  some  ill  effect,  and  I  felt  very 
much  exercised  about  it.  I  went  for  a  physician  in  whom  I 
had  a  great  deal  of  confidence.  Upon  questioning  her  and  her 
mother  he  found  that  during  the  previous  afternoon  she  had 
taken  a  cold  shower-bath,  which  had  checked  the  menstrual 
flow  and  caused  cerebral  derangement. 

"In  another  instance  a  lady  came  to  see  me  about  her  little 
girl.  Two  weeks  before,  she  had  taken  the  gas  and  now  com- 
plained that  her  child  was  feverish  and  sick,  and  had  been  so 
from  within  two  or  three  days  after  she  had  taken  the  gas.  I 
did  not  understand  it,  but  I  did  not  question  her  statement. 
After  inquiring  minutely  after  the  symptoms,  I  told  her  to 
consult  a  physician  about  it.  She  did  so  and  found  that  the 
child  was  just  being  taken  down  with  scarlet  fever.  Of  course 
there  are  many  people  who  take  the  gas  when  on  the  eve  of 
some  constitutional  change,  so  that  it  is  impossible  to  tell  what 
may  happen  at  any  time,  but  I  have  never  known  a  case  in 
which  the  ill  effects  ascribed  to  the  gas  has  not  been  capable 
of  satisfactory  explanation  to  some  other  cause.  Take  the 
case  which  has  been  mentioned  in  the  little  book  published  by 
my  brother,  in  which  a  patient  sent  for  us.  We  were  asked  in 
the  afternoon  to  go  to  the  house  and  administer  the  gas,  and 
we  could  not  do  so  until  the  next  morning.  We  got  there 
only  to  find  that  the  patient  had  died  during  the  night.  Sup- 
pose we  had  gone  the  afternoon  previous  and  given  the  gas  to 
the  patient  when  they  really  wanted  us  to  do  so,  it  would  have 
been  the  gas  that  killed  the  patient,  in  the  family's  estimation. 
To  me  it  is  really  remarkable  that  there  are  not  more  cases  of 
that  kind  happening,  because  people  die  in  the  street.  They 
are  dying  all  the  time.  They  go  through  a  great  deal  of 
nervous  excitement  attending  the  suffering  beforehand,  and 
coming  to  the  operation  is  itself  calculated  to  produce  great 
excitement,  and  it  is  a  wonder  to  me  that  persons  having 
heart  and  other  affections  do  not  have  more  trouble  than  they 
do.  I  have  investigated  a  great  many  cases  where  the  gas  was 
complained  of  as  being  the  cause  of  trouble,  and  in  every  case 
it  was  found  that  it  was  something  else. 

"  Dr.  Guilford.    Do  you  not  think,  in  the  cases  reported  years 


DANGERS   OF    NITROUS   OXIDE.  175 

ago,  these  eflfects  were  mostly  due  to  the  fact  that  the  gas  was 
either  not  pure  or  improperly  administered? 

"  Dr.  Thomas.  We  do  not  hear  of  it  nowadays.  Then  we 
had  the  gas  kept  as  long  as  we  pleased,  and  sometimes  it  was 
stated  to  have  produced  asphyxia.  As  far  as  the  cases  of  death 
which  have  occurred,  I  do  not  believe  that  one  that  has  been  re- 
ported could  be  ascribed  to  the  gas — that  is,  to  the  gas  itself, 
made  right  and  properly  administered." 

No  one  can  read  the  full  account  which  we  have  given  of 
the  physiological  action  of  this  gas  upon  the  nervous  system, 
more  especially  the  brain  and  spinal  cord,  without  perceiving 
the  powerful  impressions  which  it  makes  upon  these  important 
organs,  and  how  near  unto  death  it  may  bring  the  patient.  In 
our  own  experiments  and  those  of  Dr.  Buxton  on  the  brain  and 
spinal  cord,  we  have  met  with  dilatation  of  the  vessels,  with  of 
course  an  increased  blood  supply,  to  the  nerve  centres. 

Such  a  state  WQuld  indicate  a  condition  favorable  to  nervous 
energy,  but  this  is  soon  followed  by  interference  with  the  due 
regularity  of  the  cerebral  and  cerebellum  circulation,  if  carried 
too  far,  producing  irregular  muscular  action,  rigidity  and  nerv- 
ous exhaustion,  also  disturbance  producing  marked  reflex 
action  and  even  ankle  clonus.  Amongst  the  occasional  phe- 
nomena which  occur,  are  opisthotonus,  paralysis  of  the  bladder 
and  involuntary  action  of  the  urinary  and  rectal  secretions. 

Another  distressing  class  of  symptoms  are  the  excitation  of 
the  sexual  centres,  and  abolition  of  the  normal  checks  imposed 
upon  the  production  of  orgasm. 

In  some  cases  there  is  a  quiet  prolongation  of  nitrous  oxide 
narcosis,  unaccompanied  by  the  wild  convulsions  of  asphyxia, 
when  the  breathing  absolutely  stops  while  the  heart  beats  on. 

Fortunately  in  these  cases  artificial  respiration,  conducted 
for  one  or  two  admissions  of  air,  restores  the  patient  to 
animation,  and  all  goes  well. 

No  danger  is,  in  fact,  incurred  unless  the  anaesthetist  is 
incompetent,  or  negligent  of  his  solemn  charge. 

Theinhalationof  nitrous  oxide  gas,  long  continued,  causes  pro- 
gressive depression  of  the  vital  functions,  which,  likeall  systemic 
anaesthetics,  tends  to  death.     This  must  never  be  forgotten. 


176  ARTIFICIAL  ANESTHESIA. 

Accidents  in  Extracting  Teetli  under  Nitrous  Oxide. 

Buxton  gives  some  important  hints  in  extracting  teeth 
while  under  tlie  influence  of  nitrous  oxide  gas.  "The  mouth 
should  be  cleared  of  artificial  dentures,  especially  small  plates. 
Accidents  have  arisen  i'rom  teeth  or  portions  of  teelh,  being 
allowed  to  fall  from  the  beaks  of  forceps  back  over  the  glottis, 
a  deep  inspiration  then  drawing  the  tooth  into  the  trachea. 
The  tooth  forceps  have,  in  recorded  cases,  broken  and  a  frag- 
ment become  lodged  in  the  trachea.  All  instruments  used  for 
the  mouth  should  be  carefully  examined  for  flaws,  and  all 
gags,  props,  etc.,  should  be  secured  by  fishing  gut  or  some 
strong,  cleanly  material  and  attached  outside  the  mouth. 

"  In  extracting  teeth,  the  forceps  after  each  extraction  should 
be  wiped  twice,  as  taught  by  Clover,  before  attacking  another 
tooth.  Fragments  of  teeth  should  never  be  left  in  the  mouth, 
even  with  the  object  of  gaining  time;  each  fragment  should  be 
removed  before  any  further  proceedings  by  bending  the  head 
forward  and  sweeping  the  finger  around  the  mouth.  The  tongue 
must  not  be  drawn  forward,  as  by  so  doing  the  laiynx  will  be 
left  exposed,  the  epiglottis  being  dragged  from  it,  while  the 
patient  is  thereby  induced  to  take  a  deep  inspiration,  which  will 
probably  cause  the  foreign  body  to  enter  the  air  passage." 

In  its  pure  state  the  gas  may  be  given  to  almost  any  one,  if 
judiciously  administered. 

Among  the  diificulties  which  may  be  met  with  as  having 
the  appearance  of  danger  in  administering  nitrous  oxide,  the 
most  common  is  constriction  or  spasm  of  the  glottis  or  "  swal- 
lowing the  tongue."*  The  use  of  the  prop  cannot  be  over- 
estimated in  such  cases.  The  patient  becomes  very  dark  in 
the  face;  there  is  a  violent  exertion  of  the  diaphragm,  and  he 
presents  every  indication  of  approaching  asphyxia,  which,  by 
having  the  mouth  well  propped  open,  is  very  readily  relieved  by 
catching  hold  of  the  tongue  with  a  dry  napkin  and  pulling  it 
out  of  the  mouth,  and  at  the  same  tince  raising  the  body  for- 
ward. As  soon  as  the  patient  has  taken  two  or  three  inspira- 
tions of  pure  air  the  tension  is  relaxed,  and  recovery  will  take 

*  See  experiments  by  Drs.  Hare  and  Martin  under  "Artificial  Eespiralion,"  arti- 
cle on  chloroform. 


DANGEES    FROM   SYNCOPE.  177 

place.  Another  formidable  symptom  of  danger  in  when  your 
patient  is  attacked  with  syncope  while  under  the  influence  of 
the  gas.  Be  sure  the  air  passages  are  open  by  pulling  the 
tongue  forward.  Then,  the  patient  being  in  a  sitting  posture, 
bring  the  head  and  body  forward  with  considerable  violence, 
which  will  generally  prove  sufficient.  You  may,  however,  meet 
cases  which  will  require  more  effective  remedies.  The  object 
is  first  to  get  the  head  on  a  level  with  or  below  the  heart,  so  the 
blood  may  flow  freely  to  the  brain,  which  is  done  by  laying  the 
patient  on  the  floor;  then  throw  cold  water  violently  in  the  face. 
The  most  effectual  remedy  is  to  place  the  finger  far  down  the 
throat,  which  will  produce  involuntary  retching,  and  is  the  most 
efficient  action  to  bring  about  restoration,  after  which  treat  the 
patient  as  inanyordioary  case  of  fainting,  giving  alittle  brandy, 
ammoniated  tincture  of  valerian  or  aromatic  spirits  of  ammonia, 
ten  to  twenty  drops  doses  in  water,  and  allowing  the  patient  to 
lie  on  the  lounge  until  strong  enough  to  walk  in  the  fresh  air, 
when  he  or  she  will  soon  recover  completely. 

In  the  hands  of  a  skillful  and  careful  operator  no  great 
risk  attends  the  employment  of  this  anaesthetic;  but  those 
who  are  less  skillful,  and  are  inexperienced,  should  reject 
cases  of  great  physical  exhaustion,  or  patients  with  a  feeble  or 
fatty  heart,  indicated  by  pain  and  flushed  face.  The  disten- 
sion of  the  right  cavities,  which  accompanies  the  disappear- 
ance of  the  radial  pulse,  and  the  general  lividity  of  the  fea- 
tures, may  be  attended  with  some  degree  of  risk,  and  the 
danger  is  increased  when,  the  muscles  of  the  trunk  and  limbs 
being  convulsed,  the  pressure  of  the  contracting  muscles  upon 
the  veins  drives  the  blood  forcibly  towards  the  right  cavities  of 
the  heart,  and  so  adds  to  their  distension. 

Administering-  Mtrous  Oxide  to  Children. 

Dr.  Buxton  states  that  in  giving  nitrous  oxide  to  children, 
the  face-piece  (not  so  much  employed  in  this  country)  should  be 
removed  with  the  first  sign  of  jactitation ;  otherwise  these 
small  bodies  become  so  convulsed  that  it  is  difficult  to  keep 
them  still  for  operation,  and  much  valuable  time  is  lost  in  the 
attempt  to  place  them  in  a  convenient  position. 

8* 


178  ARTIFICIAL  ANESTHESIA. 

Deaths  from  the  Inhalation  of  Nitrous  Oxide. 

First  Case. — In  one  instance  in  this  city  of  supposed  death 
from  this  antesthetic  agent,  it  was  sirbsequently  discovered 
by  a  post-mortem  examination,  that  one  of"  the  cork  props 
which  had  no  securing-string  attached,  was  found  in  the 
larynx  of  the  patient.  Cases  have  also  occurred  in  which 
a  root  or  piece  of  tooth  has  been  drawn  into  the  trachea 
and  dislodged  by  vomiting  or  paroxysmal  coughing.  In 
one  case  the  root  of  a  tooth  was  passed  into  the  bronchia, 
and  produced  all  the  symptoms  of  phthisis;  fortunately,  at  a 
later  period,  the  root  of  the  tooth  was  caught  up,  and  the 
patient  recovered. 

Second  Case. — In  1872  a  death  was  alleged  to  have  resulted 
from  the  inhalation  of  nitrous  oxide  gas  administered  by  Dr. 
Newbrough,  of  New  York,  at  whose  office  the  death  occurred 
and  by  whom  the  following  summary  of  evidence  was  made 
before  the  coroner's  jury  : 

The  patient,  a  middle-aged  lady,  desired  the  extraction  of 
seven  or  eight  front  teeth,  which  were  loose.  Dr.  Newbrough 
advised  that  their  removal  would  be  so  easy  that  an  ansesthetic 
would  be  unnecessary;  but  the  patient  insisted  that  she  could 
not  submit  to  the  operation  without  it.  Dr.  Newbrough  then 
procured  a  six-gallon  bag  of  nitrous  oxide  gas  ;  but  the  patient 
seemed  equally  fearful  of  ansesthesia  as  well  as  pain — and,  as 
soon  as  she  had  made  the  inhalation,  rejected  the  bag  and  de- 
clared her  willingness  to  have  the  operation  performed  without 
it.  At  sight  of  the  forceps  her  courage  again  failed  her,  and  she 
decided  once  more  to  try  the  gas.  She  took  one  inhalation,  and 
again  rejected  it.  By  this  time  so  much  of  the  gas  had  escaped 
from  the  bag  that  the  doctor  replenished  it.  Of  this  she  took 
two  inhalations,  and  peremptorily  refused  to  have  anything 
more  to  do  Avith  it,  declaring  her  determination  to  submit  to 
the  operation.  The  teeth  were  then  extracted.  "Immediate- 
ly," says  the  doctor,  "she  fainted;  her  head  dropping  over 
sideways."  The  face  rapidly  became  livid,  and  finally  purple; 
respiration  falling  to  about  fifteen  per  minute.  In  about  thir- 
teen minutes,  notwithstanding  the  prompt  application  of  the 
galvanic  battery  and  efforts  to  assist  respiration,  death  ensued. 


DEATHS   FROM   NITKOUS   OXIDE.  179 

Dr.  Otis,  summoned  by  Dr.  Newbrough,  arriving  in  about 
ten  minutes  after  the  fainiing,  testified  that  he  continued  the 
usual  restorative  treatment  for  forty-five  minutes,  when  death 
ensued.  A.i post-mortem,  found  no  disease  of  the  heart;  brain 
perfectly  exsanguined  in  every  part;  no  fluid  in  any  of  the 
ventricles ;  one  lung  was  more  engorged  than  the  other,  but 
healthy.  As  the  testimony  was  very  discordant  in  several  par- 
ticulars, we  shall  give  only  the  conclusions  of  Dr.  J.  W.  White, 
who  carefully  sifted  the  whole  testimony : — 

"  Of  the  case  under  discussion,  the  inference  seems  entirely 
justified,  that  death  was  not  caused  by  nitrous  oxide  gas,  for 
the  simple  reason  (if  the  evidence  can  be  relied  upon),  that 
not  enough  was  inhaled  to  produce  such  a  result  on  any  theory 
of  its  action.  Nor  was  there  any  fact  established  by  the  post- 
mortem to  justify  such  a  conclusion;  while  the  testimony  ren- 
ders it  entirely  probable  that  the  cause  of  death  was  nervous 
shock,  from  dread  of  pain  and  apprehension  of  fatal  effect  from 
the  inhalation  of  an  anaesthetic  agent. 

"  It  may  be  remarked,  however,  that  an  examination  by  the 
coroner  as  to  the  possible  lodgment  of  an  extracted  tooth  in 
the  air-passages  would  have  eliminated  that  from  the  list  of 
uncertainties." 

Third  Case. — The  following  case  is  reported  in  the  London 
Medical  Times  and  Gazette  of  April  7th,  1877.  As  it  is  of  con- 
siderable importance,  on  account  of  the  extended  use  of  the 
anaesthetic,  we  quote  it  in  full : — 

"An  inquest  was  held  last  week,  at  Manchester,  on  the  body 
of  Mr.  George  Morley  Harrison,  aged  fifty-three,  a  surgeon 
in  good  practice  and  formerly  lecturer  on  Medical  Jurispru- 
dence at  the  Manchester  Royal  School  of  Medicine,  who  died 
whilst  under  the  influence  of  nitrous  oxide  gas,  administered 
at  his  own  request,  previous  to  having  a  tooth  extracted  by  a 
neighboring  dentist.  Mr.  Harrison,  it  appears,  being  unnerved 
and  excited,  partly  from  the  suffering  he  had  undergone  and 
partly  owing  to  the  want  of  proper  food,  which  the  condition 
of  his  mouth  had  prevented  him  from  taking,  insisted  on  the 
inhalation  being  pushed  until  he  should  snore,  and — for  at  any 
rate,  part  of  the  time — held  the  mouth-piece  in  his  own  hand, 


180  ARTIFICIAL   ANAESTHESIA. 

and  inspired  very  vigorously.  The  first  attempt  at  extraction 
was  made  before  he  was  fully  insensible,  and  was  abandoned 
until  more  of  the  gas  liad  been  given.  Eventually,  however, 
two  teeth  were  removed.  The  patient  did  not  appear  to  be 
coming  round  properly  after  the  operation,  and  the  dentist 
taking  alarm,  sent  for  medical  assistance.  On  the  arrival  of  a 
surgeon,  Mr.  Harrison  was  pronounced  to  be  quite  dead.  At 
the  post-mortem  examination  there  was  found  some  fat  about 
the  heart  ;  the  cavities  on  the  right  side  were  distended  with 
blood,  while  those  on  the  left  side  were  empty.  The  lungs  on 
both  sides  were  gorged  with  dark  blood.  All  the  other  organs 
were  healthy. 

"  The  jury  came  to  the  conclusion  that  the  deceased  '  died 
from  syncope,  during  the  administration  of  nitrous  oxide  gaa 
for  the  extraction  of  teeth,  whilst  laboring  under  fatty  degen- 
eration of  the  heart.'  " 

"A  more  full  and  careful  post-mortem  was  made  in  the 
above  case  of  death  from  nitrous  oxide.*  The  examina- 
tion of  the  body  took  place  seventeen  hours  after  death. 
Rigor  mortis  was  well  marked,  and  there  was  considerable 
post-mortem  lividity.  There  was  a  good  deal  of  fat  beneath 
the  skin,  in  the  omentum,  upon  the  external  surface  of  the 
heart,  and  in  the  usual  localities.  The  heart  and  pulmonary 
artery  were  opened  in  situ.  The  right  side  of  the  heart  was 
distended  with  tluid  blood ;  the  left  side  was  empty.  There 
were  two  or  three  slight  patches  of  atheroma  in  the  aorta, 
and  upon  one  of  the  aortic  valves.  There  was  some  little 
evidence  of  fatty  changes  in  the  slightly  altered  color  and 
consistence  of  the  walls  of  the  heart.  The  coronary  arteries 
were  examined  and  found  free  from  disease.  The  mucous 
membrane  lining  the  trachea  and  bronchi  was  congested. 
Some  mucus  was  found  in  these  tubes,  but  no  blood  or  other 
foreign  body.  There  was  distinct  thickening  of  the  aryteno- 
epiglottidean  folds  and  of  the  vocal  cords.  The  lungs  on  both 
sides  were  gorged  with  dark  fluid  blood ;  at  the  left  apex  there 
was  an  old  fibrous  cicatrix.    The  liver  was  enlarged — its  tissue 

•Medical  Times  and  Gazelie,  April  27th,  1877. 


POST-MORTEM.  181 

was  very  friable  and  of  a  dirty  yellowish-white  color.  The 
kidneys  were  full  of  blood ;  otherwise  perfectly  healthy.  The 
bones  of  the  skull  were  of  unusual  thickness.  The  visceral 
arachnoid  was  thickened  and  opaque.  On  removing  the  brain 
a  large  quantity  of  cerebro-spinal  fluid  made  its  escape,  and 
the  cornua  of  the  ventricles  were  found  dilated.  The  brain- 
substance  wa&  healthy,  and  its  vessels  full  of  blood." 

In  this  sad  case  a  most  valuable  life  was  sacrificed  almost  at 
the  patient's  own  request.  No  man  has  any  right  to  do  as  a 
patient  desires,  or  allow  him  to  be  the  judge  of  the  quantity 
of  an  anaesthetic  he  should  inhale,  as  a  patient  under  such 
circumstances  is  not  a  competent  judge. 

The  following  are  some  observations  of  that  veteran  chlo- 
roformist,  Mr.  J.  F.  Clover,  on  this  interesting  case,  addressed 
to  the  editor  of  the  British  Medical  Journal: — 

"  Sir  :  In  the  Times  of  Good  Friday  last,  there  appeared  a 
notice  taken  from  the  Manchester  Examiner  of  a  death  under 
nitrous  oxide  gas.  The  following  was  the  verdict  of  the  cor- 
oner's jury: — '  Died  from  syncope,  during  the  administration 
of  nitrous  oxide  gas  for  the  extraction  of  teeth,  while  labor- 
ing under  fatty  degeneration  of  the  heart.' 

"The  details  of  so  unusual  an  event  would  be  highly  inter- 
esting to  the  medical  profession,  to  enable  them  to  judge  of 
the  safety  or  danger  of  the  anaesthetic  used.  To  form  a  cor- 
rect opinion,  we  should  at  least  know  how  long  the  inhaler 
was  applied,  the  order  and  manner  in  which  the  movements  of 
the  heart  and  respiration  became  affected,  and  what  had  been 
swallowed  previously. 

"The  verdict  was  probably  inaccurate  in  stating  that  the 
syncope  occurred  during  the  administration  of  the  gas,  as  no 
symptoms  of  danger  were  noticed  until  after  the  extraction  of 
the  second  tooth. 

"  The  most  probable  explanation  of  this  sad  case  is  that  the 
extractions  were  difficult,  and  that  the  patient,  on  recovering 
from  the  effect  of  the  gas,  was  susceptible  to  the  shock  of  a 
severe  operation ;  and  that  this  shock,  and  not  the  gas,  was 
the  cause  of  the  syncope,  which  structural  disease  of  the  heart 
rendered  fatal.     Unfortunately,  it  appears  that  no  third  per- 


182  ARTIFICIAL   ANAESTHESIA. 

son  was  present,  and  we  cannot  expect  the  necessary  evi- 
dence from  the  operator,  whose  attention  was  otherwise  di- 
rected. 

"Those  whose  opinions  of  the  effects  of  nitrous  oxide  are 
formed  by  inferences  from  Reid's  Experiments  on  Asphyxia^ 
and  some  cases  of  cardiac  distress,  first  complained  of  after 
inhaling  gas,  will  blame  the  latter.  Those  who  daily  witness 
the  continuance  of  the  circulation,  in  spite  of  the  blood  being 
black  from  the  gas,  and  the  cheerful  and  speedy  recovery  from 
it,  will  conclude  that  so  unusual  a  result  must  have  depended 
upon  the  peculiarity  of  the  patient,  whose  heart  was  found  in 
a  state  sufficiently  diseased  to  account  for  sudden  death." 

Fourth  Case. — Fatal  results  following  the  inhalation  of  ni- 
trous oxide  in  the  case  of  Mr.  Samuel  P.  Sears,  the  operator 
being  Mr.  Jose  R.  Brunet,  D.D.S.*    No  particulars. 

Fifth  Case. — Death  from  nitrous  oxide  occurred  at  Exeter, 
England.  The  gas  was  administered  by  Dr.  F.  F.  Ma- 
son for  the  purpose  of  the  painless  extraction  of  a  large 
upper  molar  tooth.  The  lady.  Miss  Wyndham,  was  about 
thirty-eight  years  of  age,  in  good  health.  Her  physician. 
Dr.  Pattison,  was  present.  Gas  from  the  same  source  had 
been  administered  to  other  patients,  so  that  its  quality 
could  not  be  impugned.  She  took  the  gas  in  the  usual  way, 
without  any  symptoms  to  excite  uneasiness.  At  the  proper 
degree  of  insensibility,  the  gas  was  stopped,  and  the  tooth  ex- 
tracted. It  was  not  until  after  the  operation  was  completed 
that  anything  unusual  happened ;  her  face  suddenly  became 
livid,  and  the  features  began  to  swell,  and  she  seemed  to  be 
quite  unconscious.  She  breathed  two  or  three  times,  and  in  a 
few  moments  her  pulse  ceased  to  beat.  All  attempts  to  restore 
her  were  fruitless. 

"  There  was  no  obstruction  to  the  air-passages,  and  the 
tongue  was  protruded,  while  she  still  respired." 

Sixth  Case. — Tribunal  Correctional  de  la  Seine  (Fe  Chambre) 
— Homicide  through  carelessness — Anesthesia  by  means  of 
Nitrous  Oxide  Gas — Death  of  Patient — Sentence. — It  has  been 

*  Denial  Times,  vol.  1,  page  157,  New  York,  1864. 


DUCHESNE'S   CASE.  183 

shown  in  the  course  of  the  inquiry  and  trial  that  on  the  25ih  of 
November,  1884,  M.  Lejeune  went  to  Duchesne's  for  the  purpose 
of  having  a  tooth  extracted — that  at  the  patient's  request  the 
dentist  made  him  inhale  nitrous  oxide  gas  for  the  purpose  of  ren- 
dering him  insensible  during  the  operation  ;  that  as  a  result  of 
these  inhalations  M.  Lejeune  had  a  syncopal  attack  and  died. 
Considering,  that  for  this  operation,  Duchesne  made  the  mistake 
of  not  having  a  doctor  of  medicine  to  assist  him  ;  that  for  the 
administration  of  nitrous  oxide  gas,  it  is  absolutely  necessary, 
that  the  operator  should  possess  a  thorough  knowledge  of 
physiology  so  as  to  be  able  to  examine  beforehand,  and  with 
great  care,  the  state  of  the  organs  of  the  patient  who  desires 
to  be  anaesthetized;  that  whatever  may  be  the  experience  of 
the  accused,  an  experience  which  may  have  sufficed  in  most  of 
the  cases,  but  not  in  all,  Duchesne  appears  to  be  lacking  in 
special  knowledge,  and  that  he  was  neither  a  doctor  of  medicine, 
nor  an  Offieler  de  Sant6,  though  he  falsely  assumes  the  title  of 
doctor  of  medicine. 

Allowing  that  one  of  the  medical  experts  appointed  by 
the  tribunal.  Dr.  Brouardel,  who  gave  evidence  at  the  trial, 
considess  that  for  the  administration  of  anaesthetics  two  com- 
petent persons  are  required,  one  of  whom  should  be  a  doctor 
of  medicine,  and  that  it  is  most  imprudent  to  administer  an 
anaesthetic,  as  did  Duchesne,  without  fulfilling  these  conditions. 

Considering  that  if,  of  all  surgical  >  operationi^,  the  extrac- 
tion of  a  tooth  may  be  looked  upon  as  an  operation  usually  of 
slight  importance,  and  which  only  requires  some  dexterity  of 
hand,  and  may  be  thus  performed  by  any  dentist,  even  one 
who  holds  no  diploma,  the  case  is  not  the  same  when  the  op- 
eration is  performed  during  ansesthesia — that  in  the  latter 
case,  according  also  to  the  opinion  of  the  experts,  it  belongs 
uncontestably  .to  the  class  of  major  operations  that  under 
these  circumstances,  according  to  the  provisions  of  Article  29 
of  the  Law  of  Ventore  au  XI.,  Officiers  de  Santt,  and  with 
still  more  reason  dentists  who  hold  no  diploma  have  no  right 
to  perform  it  except  under  the  superintendence  and  in  the 
presence  of  a  doctor. 

Considering,  also,   that  the  present  director  of   the  EcoJe 


184  ARTIFICIAL    ANAESTHESIA. 

Deiitaire  de  Paris  does  not  hesitate  to  acknowledge  that  the 
help  of  a  doctor  is  absolutely  required  during  the  administra- 
tion of  anaesthetics  by  dentists. 

That  it  thus  appears,  from  all  that  precedes,  that  Duchesne 
in  November,  1884,  through  his  imprudence,  negligence  or 
non-observation  of  the  laws,  was  guilty,  unintentionally,  of 
homicide  on  the  person  of  M.  Lejeune,  a  misdemeanor  fore- 
seen and  puni!<hed  by  Article  319  of  the  Code  Penal, 

As  regards  the  damages  claimed  by  the  partie  civilie  (relatives). 

That  the  death  of  M.  Lejeune  must  be  looked  upon  as  due 
not  only  to  Duchesne's  fault,  but  also  to  the  imprudence  of  the 
victim  himself,  who  made  the  mistake  of  requesting  to  have 
an  anaesthetic  administered  to  him  without  having  previously 
consulted  his  ordinary  medical  attendant,  and  without  requir- 
ing the  assistance  of  any  doctor. 

For  these  reasons,  condemns  Duchesne  to  pay  a  fine  of  600 
francs,  and  also  to  pay  to  the  widow  of  Lejeune  the  sum  of 
3000  francs  as  damages. 

Annexed  are  the  views  of  Dr.  Th.  David,  director  of  the  Ecole 
Dentaire  of  Paris,  on  this  subject,  and  he  has  come  to  the  fol- 
lowing conclusions : 

L  Ansesthesia  is  to  be  looked  upon  as  one  of  the  major  sur- 
gical operations  which,  by  the  terms  of  the  Law  of  VentOre, 
are  only  to  be  performed  by  doctors  of  medicine. 

II.  Officiers  de  SanU  are  only  entitled  to  administer  anaes- 
thetics under  the  guidance  and  in  the  presence  of  a  doctor  of 
medicine. 

III.  No  one  can  pretend  that  an  operation  which  even 
Officiers  de  SantA  are  not  allowed  to  perform,  can  be  considered 
to  form  part  of  the  practice  of  the  dental  art,  and  be  permitted 
to  people  who  possess  no  medical  qualification  of  any  kind. 

IV.  Dentists  who  do  not  hold  a  diploma  and  who  adminis- 
ter anaesthetics  alone,  incur  the  penalties  edicted  against  ille- 
gal practice  of  medicine  (Arts.  35  and  36  of  the  Law  of  Ven- 
tore  an  XI),  and  in  the  event  of  an  accident,  the  penalties 
edicted  by  Article  319,  of  the  Code  Penal,  for  accidental  homi- 
cide {homicide  par  imprudence). 

Seventh  Case. — It  has  been  reported  by  Dr.  L.  P.  Tawdeli,  in 


THERAPEUTICS   OF   NITROUS   OXIDE.  ]  85 

The  Louisville  Medical  Neios,  October  23,  1880,  that  a  death 
resuhing  from  nitrous  oxide  had  occurred  in  that  place  ten  or 
twelve  years  ago,  but  no  details  have  been  given. 

A  Death  after  the  Use  of  JSHtrous  Oxide  Gas. — Samuel  J. 
Cresswell,  a  well-known  citizen,  and  proprietor  of  the  iron 
foundry  and  machine-shop  at  Twenty-third  and  Cheiry  Streets, 
Philadelphia,  was  stricken  with  paralysis  while  sitting  in  a 
dental  chair  at  the  establishment  of  Dr.  John  D.  Thomaa,  No. 
912  Walnut  Street. 

About  12  o'clock,  Mr.  Cresswell,  who  had  been  suffering  for 
several  days  with  two  painful  teeth,  went  to  Dr.  Thomas'  office 
to  have  the  troublesome  molars  drawn.  He  was  appar^ntly  in 
the  best  of  health  at  the  time,  and  after  waiting  a  few  minutes 
was  ushered  into  the  doctor's  operating  department  and  laid 
back  in  the  chair.  Dr.  Thomas,  who  is  an  expert  in  his  line, 
administered  the  gas  (nitrous  oxide),  and  in  less  time  than  it 
takes  to  write  it  a  pair  of  ugly-looking  ivories  were  on  the 
stand  at  his  side. 

Mr.  Cresswell  revived  very  quickly  from  the  influence  of  the 
gas,  and  was  straightening  himself  up  in  his  chair,  when  one 
of  his  hands  began  shaking  as  though  palsied. 

"  Why,  look,  doctor,  what  can  be  the  matter  with  me?"  he 
said,  and  then  his  speech  began  to  thicken,  and  an  instant 
after  he  fell  back  again  in  the  chair  unconscious.  All  eflbrts 
to  bring  him  to  his  senses  proved  unavailing,  and  Dr.  Thomas 
summoned  Dr.  Hobart  Hare  and  Dr.  Dry sd ale,  of  Sixteenth 
and  Arch  Street^.  Mr.  Cresswell  was  quickly  bled,  and  then, 
by  orders  of  the  physicians,  was  carried  up  to  a  bed-chamber  on 
the  third  floor  of  the  premises,  where  the  doctors  labored  with 
him  for  some  time  without  noticing  any  improvement  in  his 
condition.  Mr.  Cresswell  died  at  five  o'clock  October  12,  1889, 
aged  forty-six  years. 

Tlierapeiitic  Application  of  Nitrous  Oxide. 

Neuralgia,  uncomplicated,  will  sometimes  be  relieved  by  a 
few  inhalations  of  nitrous  oxide  gas  ;  on  the  other  hand,  if  a 
disordered  condition  of  the  stomach  cause  the  neuralgic  pains, 
instead  of  proving  a  relief,  it  will  only  aggravate  the  trouble. 


18()  ARTIFICIAL   ANyESTHFSIA. 

Nervous  Aphonia. — This  peculiar  form  of  loss  of  the  power 
over  the  voice,  usually  the  result  of  hysteria,  will  be  much 
improved  by  the  patient  inhaling  a  sufficient  amount  of  the. 
nitrous  oxide  gas  to  produce  a  partial  loss  of  sensation  and 
muscular  relaxation. 

Local  Paralysis  has  been  benefited,  where  there  was  no 
brain  lesion,  by  the  gentle  stimulation  of  the  first  stage  of 
the  gas,  or  the  tingling  and  stimulating  effect  on  the  muscles. 

Asthma. — This  disease,  when  of  a  spasmodic  character,  is 
often  much  improved,  by  causing  the  patient  to  pass  into  the 
stage  of  relaxation,  employing  it  every  other  day  for  a  week  or 
two. 

Epilepsy. — When  this  disease  is  not  the  result  of  an  organic 
change  in  the  brain,  spine  or  other  portion  of  the  nervous 
system,  but  the  result  of  some  peripheral  or  reflex  action, 
benefit  will  ensue  by  the  use  of  the  gas  for  weeks.  It  should 
be  administered  two  or  three  times  a  week  only,  to  produce 
the  stimulating  effects  of  the  first  stage  of  ana3sthesia. 

Dr.  George  J.  Zigler,*  a  friend  of  the  writer,  has  found  the 
solution  of  the  gas  in  water  of  much  utility  in  the  treatment 
of  diseased  conditions  of  certain  organs  of  the  body. 

This  gas,  we  understand,  either  al.»ne  or  mixed  with  oxygen, 
is  employed  by  certain  iildividuals  as  a  secret  remedy — a 
plausible  form  of  quackery  kept  up  by  the  most  extensive  and 
persistent  advertising. 

Therapeutics  of  Nitrous  Oxide  Gas  according  to  Dr. 
A.  M'Laiie  Hamilton. 

"For  the  relief  of  severe  paroxysms  of  neuralgic  pain,  this 
gas  stands  high  as  a  remedial  agent.  I  have  used  it  in  cases 
of  severe  and  persistent  facial  neuralgia  and  in  common 
sciatica.  When  hypodermic  injections  of  morphia  have  done 
little  or  no  good,  this  agent  offered  relief,  not  only  temporarily, 
but  in  another  way.  Just  as  oxygen  was  useful  in  the  hands 
of  Hooper,  La  Passe,  Hill,  Demarquay  and  others,  so  is  dilute 
nitrous  oxide  in  neuralgic  affections,  and  in  such  cases  the 
chemical  haematic  action  is  that  which  it  produces. 

*See  bis  work  on  this  subject. 


DR.  Hamilton's  cases.  187 

"  As  yet  I  have  not  used  the  gas  ia  the  treatment  of  Epilepsy, 
though  I  have  no  reason  to  doubt  its  value  in  a  disease  which 
is  essentially  an  anaemia.  Dr.  Smith  alludes  to  a  case  reported 
by  Wallihan,  who  had  used  mixed  nitrous  oxide  and  oxygen 
with  great  success. 

''  There  is  a  variety  of  insomnia  which  depends  upon  over- 
work and  general  prostration.  Such  a  case  came  under  my 
care,  in  the  person  of  the  President  of  a  college  who  was  on 
his  way  to  Bermuda,  in  pursuit  of  a  change  of  air  and  scene. 
He  was  persuaded  to  come  to  me  by  a  patient  who  had  taken 
the  gas.  He  had  not  slept  for  some  time,  except  for  a  few 
hours,  and  then  he  was  tortured  by  bad  dreams.  After  daily 
taking  four  gallons  of  gas  he  slept  soundly  three  nights  out  of 
four,  and  there  would  have  been  no  exception  had  he  not  ex- 
cited himself  in  preparing  for  his  trip.  In  other  cases  the  gas 
acted  very  badly  when  it  was  given  at  night,  for,  although 
drowsiness  succeeded  the  administration,  there  was  a  second- 
ary stage  of  excitement  of  a  disagreeable  kind;  T  therefore 
followed  the  suggestion  of  my  friend,  Dr.  Blake,  and  adminis- 
tered the  gas  in  the  middle  of  the  day,  and  found,  as  a  conse- 
quence, that  the  insomnia  was  overcome.  Probably  the  bene- 
ficial eflPects  arose  from  a  general  equalization  of  the  circulation, 
and  the  removal  of  effete  nervous  tissue  from  the  perivascular 
spaces.  In  such  examples  of  insomnia  dependent  upon  slow 
removal  of  waste  products  of  cerebral  action,  the  circulation 
of  vitiated  blood  in  consequence  of  hepatic  or  renal  disease, 
or  depressed  tone  of  the  cerebral  vessels,  nitrous  oxide  gas 
■was  indicated  and  tried  with  success.  In  clearly  asthenic 
cases,  however,  in  which,  the  sleeplessness  depended  upon  ex- 
citement, vascular  engorgement  of  a  congestive  character,  or 
active  cerebral  hypersemia  in  connection  with  hypertrophy  of 
the  left  side  of  the  heart,  and  increased  vascular  tension,  the 
employment  of  nitrous  oxide  was  contra-indicated,  and  did  no 
good.     In  fact,  in  one  case  it  aggravated  the  wakefulness. 

"In  some  forms  of  functional  heart  disorder  I  have  witnessed 
results  which  fulfilled  all  my  anticipations.  In  cases  con- 
nected with  hypochondriasis,  its  virtues  were  most  apparent, 
and  many  an  imaginary  trouble  ceased  to  annoy  the  patient 


188  AETIFICIAL   ANAESTHESIA. 

when  his  intellectual  functions  were  restored  to  a  normal  con- 
dition. 

"  In  one  case  of  functional  heart  trouble,  attended  by  palpita- 
tion, depression,  sinking  feelings  and  an  indescribable  pang 
which  followed  physical  exercise,  in  the  person  of  a  well- 
known  literary  gentleman  of  middle  age,  whose  sufferings 
were  dependent  upon  many  years  of  hard  intellectual  labor,  I 
was  glad  to  find  that,  after  two  or  three  days,  his  trouble  dis- 
appeared to  a  great  extent,  and  probably  in  a  younger  subject 
would  have  vanished  altogether.  In  his  case,  however,  there 
were  probably  deeper  troubles.  For  chlorotic  young  women 
who  suffer  from  ovarian  irregularities,  head  troubles  and  pal- 
pitation, nitrous  oxide  does  much  good. 

"  The  vague  muscular  pains,  irregularity  of  heart  action,  loss 
of  appetite,  tremor,  sinking  sensations  and  nervous  irritability, 
80  common  among  those  who  use  tobacco  to  excess,  form  a 
train  of  symptoms  which  disappear  very  rapidly  under  the 
influence  of  gas,  and  the  irritability  of  opium-eaters,  and  those 
who  drink  to  a  degree  that  brings  them  to  the  verge  of  acute 
alcoholism,  subsides  very  quickly.  For  this  reason  dilute 
nitrous  oxide  may  be  given  to  persons  who  suddenly  part  with 
their  accustomed  opium  or  alcohol,  and  with  a  fair  show  of 
permanent  success — for  an  agent  which  not  only  supplies  oxy- 
gen, but  improves  the  nutrition  of  worn-out  tissue,  and  sup- 
plies at  the  same  time  a  stimulant  without  reaction,  cannot 
fail  to  bridge  the  patient  over  the  period  of  acute  suffering  and 
intense  irritability  in  the  beginning." 

Dr.  Colton  on  the  Safety  in  Disease  of  Nitrous 
Oxide  Gas. 

"  Is  it  safe  in  the  various  organic  diseases,  such  as  those  of  the 
heart,  lungs,  brain,  &c.  ?  Thousands  of  invalids  have  suffered 
torture  for  months  and  years  because  they  dreaded  the  surgeon's 
knife,  and  in  like  manner,  other  thousands  suffering  from  some 
organic  or  functional  disorder  of  the  system,  have  dreaded  the 
dentist's  forceps,  and  fearing  to  take  an  antesthetic,  have  for 
years  carried  in  their  mouths  a  mass  of  filth,  a  fruitful  cause  of 
disease,  which  has  not  only  ruined  their  health  and  destroyed 


DE.  colton's  cases.  189 

their  happiaess,  but  made  them  object-j  of  repugnance  to  all 
who  are  so  unfortunate  as  to  be  associated  with  them. 

"  If  the  above  question  can  be  answered  in  the  affirmative  ;  if 
nitrous  oxide  is  safe  for  such  afflicted  ones,  it  is,  certainly,  a 
great  boon  to  suffering  humanity. 

"  Having  used  it  almost  indiscriminately  for  years,  I  present 
below  the  results  of  my  experience  : 

"  Disease  of  Lungs. — It  is  a  well-established  fact  that  pure 
nitrous  oxide  gas  is  entirely  non-irritating  to  the  lungs,  and  as 
we  have  already  shown,  its  action  upon  the  blood  is  to  increase 
the  property  of  coagulation.  A  person  who  is  predisposed  to 
hajmorrhage  can  inhale  the  gas  with  entire  immunity  from 
danger — indeed,  I  think  with  less  danger  than  would  attend 
the  operation  if  no  aneesthetic  were  administered,  since  the 
shock  to  the  system  is  thereby  avoided,  and  there  is  but  a  slight 
increase  in  the  force  of  the  circulation.  In  a  large  number  of 
such  cases  where  the  gas  has  been  administered  for  tooth- 
extraction,  I  have  never  met  with  one  where  any  haemorrhage 
followed  immediately  succeeding  the  operation,  nor  any  in 
which  the  after-effects  proved  unpropitious ;  and  this,  notwith- 
standing a  large  number  have  had  hsemorrhages  previous  to  the 
operation,  and  some  immediately  preceding  it.  I  should  state 
here  that,  in  all  cases  of  disease,  the  effects  of  the  gas  are 
watched  with  the  greatest  care,  and  if  any  untoward  symptoms 
present  themselves,  it  has  been  discontinued,  although  this  has 
never,  in  a  single  case,  been  found  necessary  until  the  patient 
was  sufficiently  under  its  influence  to  permit  of  a  momentary 
operation  ;  as  for  instance,  the  extraction  of  a  tooth. 

"Heaet-Disease. — In  this  disease  the  effects  should  be 
watched  with  care,  and  there  will  be  no  danger.  The  cumu- 
lative action  of  the  gas  is  only  for  a  few  seconds,  so  that  if  it 
be  withdrawn  at  any  time  during  the  process,  a  reaction  takes 
place  in  a  moment,  we  might  almost  say  before  the  patient  has 
time  to  die ;  while  with  ether  and  chlorofoi-m  there  is  a  cumu- 
lative action  for  from  20  to  50  seconds  after  they  have  been 
discontinued,  and  several  minutes  may  elapse  before  conscious- 
ness returns.  Although  its  evanescent  character  is  a  great 
obstacle  to  its  use  for  long  operations,  still,  that  is  the  great 


190  ARTIFICIAL   ANAESTHESIA. 

safeguard  against  accident,  for  the  heart's  action  may  be  under 
your  control,  as  the  engine  is  under  the  control  of  the  engineer. 
If  the  pressure  is  too  great,  he  lets  off  the  steam  ;  if  the 
heart's  action  is  either  increased  or  diminished  inordinately, 
remove  the  gas  and  in  a  moment  it  resumes  its  wonted  ac- 
tion. 

"  In  two  recorded  cases  the  condition  of  the  patient  was  so 
critical,  that  I  should  scarcely  have  dared  to  extract  a  tooth 
without  the  use  of  an  antesthetic,  fearing  the  shock  to  the 
system  incident  to  the  operation,  there  being  in  one  case  a 
complexity  of  diseases, — hypertrophy,  dilatation  and  valvular 
disease,  which  had  been  continued  for  12  years.  He  had 
formerly  followed  the  sea,  but  had  not  been  able  to  go  upon 
the  streets,  without  assistance,  for  several  years.  He  was  pale 
and  anaemic,  with  an  irregular  and  intermittent  pulse. 

"  The  administration  of  the  gas  was  continued  only  to  near  the 
close  of  the  second  stage;  the  patient  recovered  without  any- 
untoward  symptoms,  and  left  the  office  in  a  few  moments 
declaring  he  felt  better  than  when  he  came  in.  He  certainly 
looked  much  better,  having  lost  that  deathly  pallor  of  face 
which  he  had  when  he  sat  in  our  operating  chair.  The  danger 
in  such  cases  is  that  the  feebleness  of  the  heart's  contractile 
power,  may  cause  its  action  to  cease  altogether  during  the  period 
when  this  power  is  partially  destroyed  by  the  paralyzing  action 
of  the  antesthetic,  while  the  safety  lies  in  the  instantaneous 
reaction  after  the  withdrawal  of  the  gas. 

"  In  Chorea,  Hysteria,  Epilepsy  and  other  diseases 
dependent  upon  a  disordered  condition  of  the  nervous  system, 
it  is  productive  of  no  bad  results,  unless  it  be  pushed  too  far  ; 
while  if  only  the  second  stage  of  ansesthesia  be  produced,  so 
that  it  shall  act  as  a  stimulant  to  the  nervous  system,  and  not 
as  a  depressing  agent,  it  will  in  many  such  cases  prove  a  most 
valuable  remedial  agent. 

"  Uncomplicated  Neuralgia  is  oftentimes  instantly  relieved. 
I  could  adduce  a  hundred  instances  of  the  kind,  where  the 
patient  has  sat  down  with  a  severe  headache,  and  been  entirely 
relieved  by  a  few  inhalations  of  the  gas.  On  the  other  hand, 
if  a  disordered  condition  of  the  stomach  cause  the  neuralgic 


NITROUS   OXIDE   IN   ASTHMA.  191 

pains,  instead  of  proving  a  relief,  it  will  only  aggravate  the 
trouble. 

"A  lady  who  had  inhaled  ether  a  half-hour  previously,  for  the 
extraction  of  some  teeth,  and  had  been  unsuccessful,  came  to 
the  office  with  a  severe  headache;  she  inhaled  the  gas,  her  teeth 
were  drawn,  and  upon  recovery  she  stated  that  her  headache 
was  entirely  relieved. 

"Hysteria. — The  gas,  by  its  stimulating  action  upon  the 
nerves,  has  oftentimes  proved  beneficial  in  cases  that  have 
come  under  my  observation. 

"Such  patients  generally  leave  the  office  with  hysterical 
symptoms  much  less  aggravated  than  before  the  inhalation. 
During  the  operation,  the  friend  in  attendance  sometimes 
expresses  fears  that  the  patient  may  have  one  of  her  'nervous 
spells,'  noticing  some  contortion  of  the  face  or  movement  of 
the  hand  as  she  is  waking  from  a  dream;  but  in  a  few  moments, 
as  soon  as  complete  recovery  has  taken  place,  there  is  usually 
a  calmness  of  the  patient,  quite  surprising  to  the  attendant, 
she  being  able  to  write  her  name  with  as  steady  a  hand  as 
usual,  within  five  minutes  of  the  commencement  of  inhala- 
tion. 

"  I  have  the  record  of  an  interesting  case  of  a  young  lady, 
who  had  not  been  able  to  speak  above  a  whisper  for  several 
months  previous  to  taking  the  gas,  who,  a  few  days  subsequent, 
called  and  informed  me  with  the  greatest  delight,  that  she  had 
been  cured,  as  she  could  talk  now  as  well  as  ever. 

"  The  fact  that  she  awoke  after  the  operation  crying  out,  may 
have  had  some  agency  in  effecting  the  cure,  as  she  thus  learned 
that  she  possessed  vocal  organs  and  could  use  them. 

"  Still,  this  case,  in  connection  with  very  many  others  of  a  like 
character,  has  convinced  me  that  pure  nitrous  oxide  may  be 
employed  with  great  advantage  in  cases  of  hysteria;  while,  on 
the  other  hand,  if  it  be  impure,  either  on  account  of  its  being 
prepared  so  recently,  or  for  too  long  a  period,  or,  if  persisted  in 
beyond  the  third  stage,  it  is  absolutely  injurious. 

"Asthma. — Asthmatic  patients  express  a  sense  of  relief  after 
inhaling  the  gas,  which  in  some  instances,  at  least,  seems  to  be 
of  a  permanent  character.     A  gentleman  of  sixty  years,  whose 


192  ARTIFICIAL   ANESTHESIA. 

disease  was  inherited,  and  who  had  been  a  severe  sufferer  for 
many  years,  was  almost  entirely  relieved  for  a  whole  winter  by 
inhaling  for  a  few  successive  days,  once  or  twice  each  day,  a 
quantity  sufficient  to  produce  the  second  stage  of  anaesthesia, 
although  he  had  not  been  free  from  the  disease,  at  this  season 
of  the  year,  for  about  twenty  years. 

"  Paralysis. — Quite  a  number  of  patients  afflicted  with  par- 
alysis in  a  greater  or  less  degree,  have  come  under  my  observa- 
tion, upon  whom  tlie  gas  has  had  a  very  pleasing  effect,  in 
stimulating  the  nervous  system  to  action,  and  thus  restoring 
the  tone  of  the  paralyzed  parts,  more  or  leas  completely. 

"  One  such  case  was  that  of  a  gentleman  who  had,  for  a  long 
time,  been  afflicted  with  paralysis  of  the  bladder.  He  inhaled 
tlie  gas  upon  several  occasions,  for  the  relief  of  neuralgia. 
After  a  few  inhalations,  the  paralyzed  condition  was  much  im- 
proved, as  was  evinced  by  his  freedom  from  incontinence.  It 
is  necessary  in  such  cases  to  produce  only  the  second  stage  of 
anaesthesia. 

"  Epilepsy. — The  following  cases  of  epilepsy  are  of  consider- 
able interest : 

"Case  1. — A  young  man,  28  years  of  age,  who  had  inherited 
the  disease,  inhaled  the  gas  for  six  weeks,  two  or  three  times  in 
a  week.  During  the  first  week  he  had  three  epileptic  attacks; 
during  the  second  week,  two  ;  during  the  third,  one,  and  for  the 
three  weeks  succeeding,  not  any. 

"  I  presented  the  case,  at  the  time,  at  the  University  clinics, 
but  have  never  been  able  to  obtain  its  subsequent  history. 
Previous  to  inhaling  the  gas,  he  had  had  two  or  three  attacks 
daily,  and  he  had  not  been  free  from  them  for  so  long  a  time, 
for  several  years.  Two  years  previously  he  had  inhaled 
the  gas  for  tooth  extraction,  with  a  favorable  result,  which  he 
at  the  time  attributed  to  the  bromide  of  potassium  which  he 
was  taking. 

"  Case  2. — A  young  lady  inhaled  the  gas  as  a  remedy  in  the 
same  disease.  She  recently  informed  me  that  she  had  not  had 
an  attack  for  several  months,  although  before  this  she  had  ex- 
perienced them  frequently.  She  attributes  her  freedom  from 
attacks  to  the  remedial  efficacy  of  the  gas." 


clover's  inhaler.  193 

Nitrous  Oxide  and  Oxyg-en  as  an  Anaesthetic  in 
Labor. 

The  great  advantages  of  nitrous  oxide  as  an  anaesthetic,  have 
induced  various  observers  to  endeavor  to  find  a  method  of  ad- 
ministering the  gas  continuously,  so  as  to  keep  up  the  anaes- 
thetic influence  for  a  sufiicient  length  of  time  for  the  perform- 
ance of  surgical  operations. 

Paul  Bert,  some  years  ago,  made  experiments  with  animals 
in  a  chamber  of  compressed  air,  a  mixture  of  nitrous  oxide  and 
oxygen  being  inhaled. 

He  found  that  anaesthesia  could  be  kept  up  for  a  long  period, 
and  he  urged  the  construction  of  such  chambers  for  operating 
upon  the  human  subject. 

Some  few  experiments  were  made  in  minor  surgery,  but 
nothing  on  a  large  scale  was  attempted  on  account  of  the  ex- 
pense, etc. 

In  1881,  Dr.  Si  Klikovich,  in  St.  Petersburg,  made  some  ex- 
periments on  himself  with  a  mixture  of  nitrous  oxide  and 
oxygen,  in  the  proportion  of  80  to  20,  without  any  increase  of 
atmospheric  pressure,  with  a  satisfactory  result.  He  also  used 
it  for  alleviating  the  pains  of  labor,  and  found  it  very  success- 
ful and  perfectly  safe,  the  great  objection  to  it  being  its  expense, 
and  the  cumbersome  nature  of  the  required  apparatus. 

Professor  Zweifel,  of  Erlangen,  erected  the  necessary  appa- 
ratus for  the  supply  of  the  mixed  gases  to  the  accouchement 
ward  of  his  obstetric  clinic.  He  finds  it  best  to  administer  the 
gases  continuously  during  the  latter  part  of  the  labor,  when 
the  pains  are  most  severe,  not,  as  was  practiced  by  Klikovich, 
merely  giving  the  gases  when  signs  of  approaching  pain  ap- 
peared. 

Though  this  treatment  had  been  adopted  in  sixty  patients, 
no  retardation  of  the  process  was  observed. — B.  Med.  Journal, 
Nov.  7,  1885. 

Clover's  Inhaler  for  Mtroiis  Oxide  Gas  and  Ether. 

(See  illustration,  page  141.) 

The  following  is   a  description  of   the  apparatus  of  Dr. 
Clover,  and  his  valuable  conclusions : — 
9 


194  ARTIFICIAL   ANAESTHESIA. 

The  apparatus  consists  of  a  thin  bag,  oval  in  shape,  and  fif- 
teen inches  long  ;  at  one  end  connected  with  the  ether  vessel, 
at  the  other  with  the  face-piece.  Inside  the  bag  there  is 
a  flexible  tube  also  connected  with  the  face-piece  and  ether 
vessel. 

By  turning  the  regulator  (Re)  the  patient  is  made  to  breathe 
ether  directly  into  the  bag,  or  indirectly  through  the  tube  or 
ether  vessel. 

When  the  letter  G  is  visible,  the  way  to  the  gas-bag  is  open  ; 
when  the  letter  E  is  visible,  the  only  way  to  the  bag  is  through 
the  tube  and  ether  vessel ;  so  that  the  more  the  regulator  is 
turned  toward  E,  the  more  ether  is  given,  and  vice  versa.   ■ 

The  other  vessel  contains  a  reservoir  of  water  to  prevent  the 
temperature  of  the  ether  becoming  too  low  ;  this  is  to  be  kept 
full. 

The  ether  vessel  is  to  be  rather  more  than  half  filled,  the  pre- 
cise point  being  marked  against  the  glass  gauge.  A  thermom- 
eter inside  this  gauge  tells  the  temperature  of  the  ether.  Before 
using  it,  the  vessel  should  be  dipped  into  a  basin  of  warm 
water,  and  rotated  until  the  thermometer  stands  at  about  68°. 

If  the  room  be  cold,  and  if  the  patient  have  thin  cheeks  and 
large  whiskers,  the  temperature  may  be  73°. 

It  is  important  that  the  face-piece  should  fit  closely  against 
the  face.  Those  made  by  Mayer,  of  solid  leather  framework 
supporting,  a  collar  of  inflated  india-rubber,  are  the  best,  but 
sometimes  they  require  to  be  warmed  before  using.  For  giving 
nitrous  oxide  only,  the  regulator  is  turned  to  G.  The  stojjcock 
of  the  ether  vessel  is  closed. 

This  vessel  is  hooked  upon  the  strap  around  the  neck.  The 
strap  is  adjusted  so  that  the  ether  vessel  stands  at  a  higher  level 
than  the  face-piece. 

The  gas  being  turned  on  by  rotating  the  foot  key  with  the 
foot,  the  gas-bag  is  kept  filled  as  fast  as  it  is  emptied  by  the 
patient.  When  the  latter  breathes  out,  the  supply  of  the  gas  is 
stopped,  and  after  the  bag  is  fully  distended,  the  escape-valve 
opens,  and  allows  the  expired  gas  to  escape. 

If  the  shape  of  the  patient's  face  prevents  the  face-pieces  from 
fitting  closely,  the  escape- valve  should  be  closed  by  pressing  it 


HINTS   BY   CLOVER.  195 

with  the  fijiger.  Enough  gas  will  escape  beneath  the  face-piece 
during  the  expiration.  But  the  bag,  being  slightly  distended, 
will  yield  the  gas  so  abundantly,  that  no  air  will  be  drawn  in  at 
the  same  place  during  the  inspiration. 

If  ether  is  to  be  used  without  gas,  the  gas-tube  should  be 
taken  off  the  ether  vessel,  the  regulator  should  be  turned  to  G, 
and  the  face-piece  should  be  first  applied  to  the  face  during  an 
expiration,  and  be  held  rather  closer  during  expiration  than 
during  inspiration. 

It  is  important  not  to  oblige  the  patient  to  inhale  after  the 
bag  is  empty,  because  the  barometric  pressure  of  air  on  the 
ether  being  diminished,  the  vapor  would  increase  in  strength, 
and  make  the  patient  cough  or  perhaps  vomit. 

The  regulator  is  gradually  turned  towards  E,  and  thus  the 
way  is  opened  to  the  inner  tube.  The  air  breathed  through  it 
carries  vapor  from  the  vessel  into  the  distal  end  of  the  bag. 

As  soon  as  one-half  of  the  air  passes  through  the  ether  ves- 
sel, the  vapor  becomes  strong  enough  to  cause  insensibility  in 
about  two  minutes,  usually  without  any  coughing.  As  the 
movement  of  swallowing  is  excited  by  a  too  strong,  although 
less  pungent,  atmosphere  than  is  generally  needed  to  excite 
coughing,  it  should  be  watched  for,  and  the  regulator  slightly 
turned  back  if  it  occur. 

By  far  the  easiest  and  least  unpleasant  way  of  getting  a 
patient  ready  for  a  surgical  operation,  is  to  use  gas  and  ether 
combined,  the  gas  being  given  pure  during  four  or  five  respira- 
tions, and  the  ether  gradually  added  as  above  described. 

The  supply  of  gas  should  cease  when  the  ether  is  turned  on  ; 
but  if,  during  the  operation,  we  have  admitted  so  much  fresh 
air  that  the  patient  seems  conscious  of  the  taste  of  ether,  we 
may,  instead  of  increasing  the  ether,  give  a  liberal  supply  of 
gas  until  the  patient  is  tranquil. 

We  find  less  sickness  and  less  complaint  of  the  taste  of  ether 
afterwards,  than  when  ether  is  used  alone. 

In  operations  on  the  eye,  the  muscular  twitching  and  panting 
character  of  the  breathing  during  the  first  few  minutes  of  in- 
sensibility, are  objectionable;  but  if  the  operation  be  not  com- 
menced for  five  minutes,  and  the  ether  given  as  strong  as  it  can 


196  ARTIFICIAL   ANESTHESIA. 

be  taken  without  exciting  a  cough,  the  patient  begins  to  breathe 
Btertorously,  and  now  the  face-piece  may  be  removed  every  third 
or  fourth  inspiration,  and  aa  the  stertor  goes  off,  the  eye  will 
become  quite  steady. 

He  is  so  well  satisfied  with  a  modification  of  his  chloroform 
apparatus,  by  which  he  can  give  as  much  of  ether  or  chloroform 
as  he  likes,  that  when  he  has  a  choice  he  prefers  using  the.<e  for 
cataract  operations,  and  for  the  ligature  of  deep-seated  arteries, 
etc. 

With  respect  to  vomiting,  it  is  most  important  that  the  pa- 
tient should  have  an  empty  stomach,  and  prefer  that  neither 
food  nor  drink  of  any  kind  should  be  taken,  for  from  four  to  six 
hours  beforehand. 

There  is  less  sickness  after  operations,  if  done  before  break- 
fast. 

In  using  this  apparatus,  as  in  using  others,  the  breathing  and 
the  pulse  should  be  kept  under  observation. 

Whenever  a  patient  is  seen  to  swallow,  it  is  probable  he  is 
taking  the  vapor  stronger  than  is  necessary,  and  the  regulator 
should  be  turned  back  slightly. 

If  the  patient  cough  violently,  remove  the  face-piece,  and  be 
sure  that  the  apparatus  has  not  been  overheated  or  filled  with 
ether  above  the  proper  level. 

Aa  soon  as  any  muscular  twitchings,  like  those  of  paralysis 
agitans,  are  seen,  give  about  a  fourth  of  an  inspiration  of  fresh 
air,  and  do  not  keep  the  face-piece  quite  close  to  the  face  till 
the  twitchings  have  nearly  ceased.  , 

He  has  never  seen  any  harm  result  from  the  condition  which 
causes  these  movements.  If  air  were  not  given,  they  would 
increase,  and  then  stop ;  the  respiration  would  become  inter- 
mittent, and  some  time  after  this  the  heart  would  cease  to 
beat. 

The  fact  that  death  may  be  produced,  if  signs  of  danger  are 
disregarded,  applies  to  all  anaesthetics. 

Whenever  the  breathing  becomes  jerking,  sobbing,  or  inter- 
mittent, the  face-piece  should  be  removed,  but  applied  directly 
the  breathing  loses  that  character,  unless  the  pulse  is  much  de- 
pressed. 


HINTS   BY   CLOVER.  197 

It  is  much  less  important  to  watch  the  pulse  whilst  giving 
gas  and  ether,  than  in  giving  chloroform ;  but  it  is  desirable,  for 
when  it  decidedly  loses  power,  we  may  safely  admit  a  little 
fresh  air,  and  thus  anticipate  the  need  of  removing  the  face- 
piece  to  a  greater  extent  on  account  of  muscular  twitching  or 
stertor. 

If  the  iSnger  be  taken  from  the  pulse  to  do  something  else, 
it  is  well  to  give  a  little  air,  unless  the  patient  had  only  just  be- 
gun to  inhale,  or  was  evidently  but  slightly  under  the  anses- 
thetic. 

Practical  suggestions : — 

As  the  apparatus  would  be  injured  by  an  excited  patient 
taking  hold  of  it,  it  is  as  well  to  have  an  assistant  near  in  case 
of  need. 

It  is  a  good  plan  to  place  a  handkerchief  over  a  patient's 
eyes,  and  keep  it  there  until  he  is  asleep,  and  apply  it  again 
when  he  is  about  to  awake. 

In  operations  on  the  rectum,  it  is  desirable  that  the  bandage 
required  for  keeping  him  on  his  side  should  be  applied  before 
giving  the  gas. 

Sudden  distension  and  bursting  of  the  gas-bag,  or  gas-tube,  can 
scarcely  happen  when  the  gas  rarefier  is  used ;  but  if  this  be  not 
used,  or  if  the  gas-bottle  has  become  frozen,  it  is  desirable  to 
warm  the  bottle,  and  in  doing  so,  the  top  end  should  be  more 
warmed  than  the  other. 

Whenever  there  is  much  diflBculty  in  getting  the  face-piece 
adjusted,  it  may  be  necessary  to  arrange  a  handkerchief  or  towel 
so  that  the  air  drawn  in  under  the  face-piece  may  be  nearly  the 
same  as  that  which  was  breathed  out. 

In  conclusion,  the  advantages  of  the  apparatus  are  these: — 

1.  It  lessens  the  waste  of  ether,  and  consequently  the  odor 
of  ether  about  the  house. 

2.  The  patient  usually  goes  to  sleep  without  any  struggling, 
and  is  ready  to  be  operated  on  in  from  one  to  two  minutes. 

3.  The  percentage  of  ether  need  not  be  so  high  as  to  produce 
coughing  or  swallowing,  and  it  can  be  made  stronger  or  weaker, 
as  we  wish,  by  merely  turning  a  regulator. 

Lastly,  patients  recover  rapidly,  with  less  delirious  excite- 


198  ARTIFICIAL  ANESTHESIA. 

ment  and  less  sickness,  than  if  ether  be  given  in  the  usual 
way. 

Dr.  F.  N.  Otis,  of  New  York,  exhibited  Clover's  apparatus 
for  administering  ether  and  nitrous  oxide,  and  remarked  that  it 
had  given  him  the  best  satisfaction  of  any  apparatus  he  had 
ever  employed,  for  anajsthesia  was  readily  produced  without  a 
struggle  upon  the  part  of  the  patient.  It  could  be  used  for  the 
administration  of  laughing-gas  without  producing  any  of  that 
dreadfully  suffocative  appearance  so  commonly  attending  its 
use  by  the  methods  usually  employed.  He  thought  well  of 
prefacing  the  ether  by  the  use  of  a  moderate  amount  of  nitrous 
oxide. 

How  SHALL  NiTKOUS  OxiDE  AND  ETHER  BE  ADMINISTERED ? 

— Dr.  Frederick  W.  Silk,  of  London,  an  anaesthetist  of  wide  expe- 
rience, has  invented  a  useful  apparatus  for  the  production  of  an- 
aesthesia by  the  combined  method.  In  placing  his  invention 
before  the  profession.  Dr.  Silk,  himself,  comments  on  the  striking 
similarity  in  the  principle  applied  by  him  and  that  of  Dr. 
Hewitt,  who  had  pursued  an  independent  line  of  work.  The 
only  difference  between  the  apparatus  of  Dr.  Silk,  and  that  of 
Dr.  Hewitt,  is,  that  the  valve  arrangement  between  the  face- 
piece  and  the  ether-chamber  in  Dr.  Hewitt's  apparatus,  has  been 
transferred  by  Dr.  Silk,  to  the  face-piece  itself,  where  it  is  con- 
trolled by  the  fingers  of  the  hand  holding  the  face-piece  in  po- 
sition. Dr.  Silk  and  Dr.  Hewitt  have  both  attained  a  method 
greatly  superior  to  the  usual  one  of  an  ether  chamber  suspended 
around  the  neck,  and  connected  with  a  face-piece  by  means  of 
the  bag  enclosing  the  tube.  Dr.  Silk,  however,  considers  the 
new  method  still  defective,  because  of  the  diflBculty  of  admin- 
istering nitrous  oxide  with  a  mere  "  whiff"  of  ether,  as  in  dental 
work.  The  ether  chamber,  when  charged  so  that  the  indicator 
stands  at  0,  is  so  constructed  that  it  is  almost  impossible,  in 
warm  weather  especially,  to  prevent  a  very /listinct  and  dis- 
agreeable odor  of  ether  from  pervading  the  face-piece  at  all 
times.  Dr.  Silk  says  that  this  apparently  trifling  objection  be- 
comes a  serious  one  in  the  treatment  of  nervous  and  excitable 
patients. 
Another  difficulty  is  the  total  exclusion  of  air,  which  ia  so 


DEATH    FEOM    NITROUS   OXIDE   AND    ETHER.     199 

important  a  feature  ia  the  administration  of  nitrous  oxide. 
Complicated  mechanism — valves,  stopcocks,  chamber  and  pipe 
adjustments — renders  this  total  exclusion  difficult  just  so  soon 
as  the  effects  of  wear  and  changes  of  temperament  are  manifest 
in  the  apparatus,  and  notably  toward  the  close  of  the  adminis- 
tration, when  the  bag  is  becoming  empty,  and  the  inspiratory 
effort  is  greater.  Dr.  Silk  says  that  the  gas  reservoir  should  be 
brought  as  near  the  mouth  as  possible  in  all  cases,  and  especi- 
ally when  it  is  narrow,  with  various  divisions  made  by  joints, 
valves,  etc.  There  is  always  the  possibility  of  leakage,  and  gas 
is  moreover,  but  feebly  mobile. 

In  cases  where  nitrous  oxide  and  ether  are  administered  in 
succession,  Dr.  Silk  finds  his  apparatus  often  useful  in  abolish- 
ing the  pulmonary  spasm,  and  the  struggling  which  is  manifest 
in  the  later  stages  of  narcosis ;  but  he  expresses  disappointment 
that  these  phases  have  not  been  entirely  abolished,  and  that  in 
some  instances  they  have  seemed  to  be  intensified.  This  he 
attributes  largely  to  the  greater  rapidity  with  which  nitrous 
oxide  narcosis  is  produced,  as  compared  with  that  following 
ether,  the  former  growing  quite  profound  before  the  latter  has 
reached  the  first  stage.  The  consequent  necessity  for  admitting 
air  at  that  period,  retards  the  development  of  the  final  stages  of 
ether  narcosis,  and  prolongs  or  even  intensifies  the  stage  of 
struggling  and  excitement.  In  commenting  on  Dr.  Hewitt's 
and  his  own  apparatus.  Dr.  Silk  says :  "  I  am  bound  to  con- 
fess, however,  that  it  is  a  very  distinct  improvement  on  old 
methods,  and  that  I  still  continue  its  use." — Medical  Register, 
Oct.,  298. 

Death  under  the  Administration^  of  Nitrous  Oxide 
AND  Ether. — "  A  death  has  taken  place  in  London,  at  Univer- 
sity College  Hospital,  during  anaesthesia  from  nitrous  oxide  gas 
and  ether,  being,  we  believe,  the  first  fatal  case  which  has  oc- 
curred that  can  b©  attributed  to  this  combination  of  anaesthetics. 
The  patient  was  a  woman  fifty-five  years  of  age,  who  was  ad- 
mitted to  the  hospital  in  consequence  of  strangulated  femoral 
hernia.  When  admitted,  she  was  in  a  very  weak  and  exhausted 
condition  from  constant  vomiting,  the  hernia  having  been 
strangulated  for  over  forty-eight  hours.     She  was  taken  into  the 


200  ARTIFICIAL  ANESTHESIA. 

operating-theatre,  and  gas  and  ether  administered  by  means  of 
Clover's  apparatus.  In  about  four  minutes  she  was  well  under 
the  influence  of  the  anaesthetic,  without  having  exhibited  any 
previous  excitement.  Taxis  was  then  applied,  when  almost 
immediately  the  patient  became  pale,  and  recommenced  vomit- 
ing stercoraceous  matter.  At  the  same  time  the  respiration 
became  weak,  and  the  pulse  at  the  wrist  imperceptible.  The 
doors  and  windows  of  the  theatre  were  at  once  thrown  open, 
and  artificial  respiration  was  carried  on  for  a  few  minutes.  As 
no  obvious  benefit  resulted,  an  enema,  containing  three  ounces 
of  brandy  was  administered.  Fumes  of  strong  ammonia  were 
applied  to  the  nostrils,  and  ammonia  injected  into  the  right 
median  basilic  vein,  but  all  without  any  good  result,  and  the 
patient  died  within  about  ten  minutes  from  the  onset  of  the 
alarming  symptoms.  At  the  autopsy,  stercoraceous  matter  was 
found  in  the  trachea  and  right  bronchus.  The  right  side  of  the 
heart  and  the  large  veins  were  full  of  dark  fluid  blood.  The 
ventricular  walls  were  thin  and  flabby,  and  the  cavities  slightly 
dilated.  The  left  ventricle  was  empty.  The  arch  of  the  aorta 
presented  numerous  patches  of  atheroma."  * 

Sir  Henry  Thompson  recommends  Mr.  Clover's  plan  of  ad- 
ministering nitrous  oxide  gas  for  thirty  seconds,  and  then 
ether.-j- 

Mixtiires  of  Nitrous  Oxide,  Etliers,  Chloroform  and 
Alcoliol  for  Inhalation. 

In  our  numerous  experiments  with  the  various  anaesthetic 
agents,  we  have  always  found  it  diflicult  to  make  any  true 
chemical  combination.  Most  of  the  vapors  diff'er  very  much 
in  density,  and  are  given  off  at  different  temperatures,  the 
vapor  of  chloroform  being  four  times  heavier  than  air;  and 
unless  some  means  are  employed  to  keep  them  in  motion,  the 
denser  vapor  will  gravitate  to  the  bottom.  Such  is  also  the 
case  wiih  the  liquid  anaesthetics.  They  will,  when  shaken 
up,  look,  for  the  time,  a  perfect  mixture;  but  if  allowed  to 
stand,  the  heavier  liquid,  like   chloroform,  will  sink   to  the 

*  Medical  Times  and  Gazette,  March  17th,  1877. 
t  London  Lancet,  January  8th,  1876. 


MIXED   ANiESTHETICS.  201 

bottom,  and  if  the  bottle  is  not  well  shaken  each  time 
when  used,  the  patient  is  apt,  during  the  conclusion  of  a 
tedious  operation,  to  receive  the  chloroform  almost  pure. 
The  combination  of  nitrous  oxide  with  ether  had  been 
carried  out  in  England  for  many  years,  and  we  have  given 
a  description  of  Clover's  apparatus,  with  his  careful  directions 
for  use.  Then  we  have  the  useful  inhaling  apparatus  of  Dr. 
Buxton,  of  London,  with  a  reference  to  that  of  Drs.  Silk  and 
Hewitt;  also  that  of  Drs.  Codman  and  Shurtleff,  of  Boston. 
Another  convenient  attachment  has  been  arranged  by  Dr.  A. 
M.  Long,  by  which  the  nitrous  oxide  gas  is  condensed  into  a 
liquid,  and  then  mixed  with  ether,  drop  by  drop,  in  a  combi- 
ning chamber.  This  apparatus  has  been  employed,  to  a  lim- 
ited extent,  at  the  Philadelphia  Dental  College,  combining 
from  twenty  to  thirty  drops  of  ether  to  five  gallons  of  the  gas. 
It  is  well  known  that  both  nitrous  oxide  gas  and  ether  are 
stimulants,  and  this  combination  should  never  be  given  to 
persons  of  full  habit  or  flushed  face,  for  fear  of  overaction  of 
the  vessels  of  the  brain,  producing  convulsion  or  apoplexy. 
Mixtures  of  chloroform  and  nitrous  oxide,  or  chloroform,  al- 
cohol and  nitrous  oxide,  in  the  proportions  of  from  five  to  six 
drops,  to  five  gallons  of  the  gas,  have  been  employed ;  but  the 
fear  is,  that  unscrupulous  persons  would  not  limit  themselves 
to  this  quantity,  but  would  use  a  larger  proportion,  running 
the  risk  of  destroying  their  patient. 

We  have  already  given  our  opinion  of  preparatory  anaes- 
thetic combinations  of  various  agents  to  disguise  the  taste  and 
smell  of  the  ansesthetic,  under  bromide  of  ethyl,  and  would 
advise  all  persons  administering  anaesthetics  to  be  sure  of  the 
agent  they  employ,  so  as  to  be  able  to  counteract  any  danger- 
ous element. 

A  mixture  of  nitrous  oxide  and  ether  vapor  would  explode 
on  contact  with  flame  or  even  a  spark.  It  would  not  be  spon- 
taneously explosive,  and  would  not  be  more  dangerous  than  a 
mixture  of  ether  vapor  and  air. 

9* 


202  AETIFICIAI.   ANESTHESIA. 

Oxy8:on  Gas  as  an  Anaesthetic. 

Dr.  Gray,  of  Richmond,  Va.,  published  in  August,  1874, 
some  observations  regarding  pure  oxygen  aa  an  anajsthetic  for 
short  operations. 

The  Doctor  made  six  experiments  with  the  gas,  the  only  test 
cases  being  in  two  patients.  The  first,  a  colored  boy,  took  three 
gallons;  pulse  80,  respiration  24,  temperature  98°  F.  In  one 
minute  and  a  half,  the  pulse  rose  to  104,  very  feeble  and  inter- 
mitting ;  patient  profoundly  unconscious.  Dr.  Wood  extracted 
one  root,  a  superior  molar  ;  no  complaint  whatever  was  made, 
nor  was  there  the  slightest  evidence  or  symptom  of  pain.  The 
remaining  two  roots  were  now  quickly  taken  out,  with  a  scarcely 
audible  groan  on  the  part  of  the  patient.  In  two  and  a  half 
minutes  he  was  fully  reinstated,  and  said  he  did  not  know  when 
the  tooth  was  taken  out ;  that  his  first  sensation  "  was  pleas- 
ant,'' the  last  "  like  that  other  gas,"  alluding  to  nitrous  oxide, 
which  he  had  taken  on  a  former  occasion.  He  remained  seated 
in  the  dental  chair,  and  in  ten  minutes  his  pulse  was  80,  regu- 
lar; respiration  16,  temperature  (interclavicular  space)  101°  F. 

In  the  sixth  experiment,  Dr.  Wood  administered  to  Mrs.  A. 
B.  two  gallons  of  the  same  gas,  and  while  under  its  influence, 
extracted  eight  anterior  inferior  teeth  (temperature,  pulse  or 
respiration  not  taken).  The  lady  declared  she  "suffered  no 
pain  whatever." 

These  were  the  only  minor  surgical  operations  undertaken 
under  the  influence  of  the  gas.  In  the  other  four  cases,  the 
true  effects  of  the  gas  were  manifest,  i.e.,  slight  exhilaration, 
but  no  intoxication,  lips  and  forehead  purple,  partial  asphyxia, 
and  in  one  case  great  cardiac  excitement,  differing  from  that  of 
nitrous  oxide  gas,  with  which  the  gentleman  was  very  familiar, 
having  frequently  inhaled  it. 

I  feel  satisfied  from  these  experiments,  and  those  of  Pfliiger 
and  others,  reported  by  Prof.  Carpenter,  that  pure  oxygen  gas 
is  not  a  true  antesthetic.  He  states  :  *  "  The  respiration  of  pure 
oxygen  for  short  periods,  seven  to  seventeen  minutes  in  man, 

*  Effects  of  respiration  of  pure  oxygen.  Carpenter's  "Principles  of  Human  Physi- 
ology," 187U,  p.  403. 


OXYGEN    GAS   AS    AN   ANiESTHETIC.  203 

produces  no  effect  either  in  the  rapidity  of  the  pulse  or  upon 
the  temperature  of  the  body,  and  scarcely  any  more  of  this  gas 
is  absorbed,  than  under  ordinary  circumstances,  which,  as  Pflii- 
ger  has  shown,  is  owing  to  the  fact  that  arterial  blood  is  charged, 
normally,  with  nine-tenths  of  the  whole  amount  of  oxygen  it 
can  take  up.  In  small  chambers  the  whole  of  the  oxygen  is 
used  ;  but  if  the  chamber  be  large,  the  amount  of  carbonic  acid 
produced  proves  fatal  before  the  complete  consumption  of  the 
oxygen.  Thus,  Bert  observed  that  when  an  animal  was  placed 
in  an  atmosphere  of  pure  oxygen,  with  no  provision  for  the 
removal  of  the  carbonic  acid  eliminated,  death  took  place  when 
the  proportion  of  this  gas  amounted  to  from  twenty-six  to 
thirty  per  cent.,  although  the  quantity  of  oxygen  (seventy  to 
eighty  per  cent.)  was  still  found ;  when  all  the  carbonic  acid 
eliminated  was  removed,  death  occurred  in  mammals  when  the 
amount  of  oxygen  had  fallen  to  two  per  cent.,  and  in  birds 
when  it  was  reduced  to  between  three  and  four  per  cent.  He 
further  found,  that  animals  made  to  breathe  oxygen  at  a  pres- 
sure of  five  or  six  atmospheres,  or  which  are  exposed  to  ordi- 
nary air  at  a  pressure  of  twenty  atmospheres,  fall  into  violent 
convulsions,  which  last,  even  after  the  pressure  has  been  reduced 
to  the  normal.  It  would  therefore  appear  that  the  oxygen,  in 
entering  the  body  at  this  high  pressure,  forms  one  or  more  com- 
pounds with  some  of  its  constituents,  acting  like  strychnia." 

Nitrogen  and  hydrogen  may  be  considered  as  indifferent 
gases,  proving  fatal  in  a  state  of  purity  by  permitting  the  ac- 
cumulation of  carbonic  acid  in  the  blood  ;  as  the  carbonic  acid 
replaces  the  oxygen,  patients  become  livid,  and  to  every  exter- 
nal sign  utterly  insensible.  All  the  true  ansesthetics  produce 
more  or  less  asphyxia,  but  must  have  another  property,  that  of 
producing  exhilaration  or  intoxication. 

Having  read  with  pleasure  the  experiments  of  Dr.  A.  H. 
Smith,  of  New  York,  on  oxygen  gas,  I  addressed  him  a  note, 
and  received  an  answer,  a  part  of  which  is  as  follows : 

"In  all  my  experiments  with  oxygen,  and  I  often  gave  it 
very  freely,  I  never  observed  any  ansesthetic  effect.  I  have  no 
means  of  referring  to  Dr.  Gray's  article,  but  I  suspect  that  in 
cases  in  which  anaesthesia  has  been  observed  while  oxygen  was 


204  ARTIFICIAL  ANAESTHESIA. 

being  inhaled,  it  was  due  to  a  number  of  very  deep  inspirations, 
succeeding  each  other  rapidly,  which  we  all  know  will  produce 
a  slight  degree  of  antesthesia,  even  when  common  air  is  re- 
spired. I  have  often  breathed  pure  oxygen  for  several  minutes 
at  a  time,  without  experiencing  anything  more  than  a  slight 
sensation  of  pressure  or  weight  above  the  eyes ;  a  few  patients 
have  complained  of  slight  giddiness." 

As  some  persons  might  desire  to  test  for  themselves  oxygen 
gas,  either  with  nitrous  oxide  or  alone,  as  an  anaesthetic  or 
therapeutic  agent,  I  am  enabled,  through  the  kindness  of  S.  S. 
White  &  Co,,  to  show  the  complete  apparatus  which  they  now 
manufacture  for  the  use  of  dentists  and  physicians, 

Piire  Oxygen  and  Ai>i)aratiis  for  its  Therapeutic 
Administration. 

The  value  of  pure  oxygen  in  the  treatment  of  various  dis- 
eases, has  been  generally  admitted  by  the  medical  profession, 
but  the  difficulties  of  proper  generation  and  convenient  admin- 
istration, have  heretofore  been  serious  obstacles  in  the  way  of 
its  general  use.  At  the  solicitation  of  a  number  of  medical 
practitioners  interested  in  the  therapeutic  uses  of  oxygen,  S.  S, 
White  &  Co.  have  devised  an  apparatus  for  its  administration, 
both  by  inhalation  and  by  enema,  which  overcomes  all  the  diffi- 
culties formerly  encountered,  and  which  will,  we  believe,  meet 
all  the  requirements  of  safe  transportation,  easy  keeping  and 
convenient  administration. 

In  both  of  these  apparatuses,  the  administration  is  absolutely 
under  the  control  of  the  operator  in  charge,  and  we  believe 
they  will  be  found  to  be  the  most  convenient  and  economical 
on  the  market. 

The  Inhalation  Apparatus,  it  will  be  seen  (Plate  18),  is  a  modi- 
fication of  the  nitrous  oxide  apparatus,  to  adapt  it  to  the  needs  of 
oxygen  exhibition.  A,  represents  the  cylinder  filled  with  com- 
pressed oxygen  ;  B,  the  gas-valve  ;  C,  a  rubber  bag,  holding 
three  pints;   D,  a  wash-bottle  half-filled    with  water;*    E,  a 

*  The  wash-bottle  serves  several  important  purposes :  indicates  how  fast  the  gas 
is  flowing  ;  calls  attention  if  the  valve  of  the  cylinder  be  not  closed  tightly;  arrests 
any  dust  that  might  be  carried  from  the  cylinder  or  from  the  interior  of  the  tubing 
or  bag;  and  moistens  the  gas,  thus  preventing  its  absorbing  moisture  from  the 
throat  and  air-paseages. 


OXYGEN   IN   THERAPEUTICS. 


205 


mouth-piece  attached  by  a  rubber  tube  to  the  bottle;  F,  a  rub- 
ber tube  connecting  the  rubber  bag  to  B ;  and  G,  a  rubber  tube 
connecting  the  bag  to  the  wash-bottle  by  means  of  a  glass  tube 
which  extends  nearly  to  the  bottom  of  the  bottle. 


Plate  18. 


INHALATION   APPARATUS. 


In  using  the  apparatus,  arrange  the  parts  as  shown  in  the  cut, 
being  careful  to  place  the  leather  washer  properly  at  the  outlet 
of  tbe  valve  B,  and  half  fill  the  bottle  D,  with  water.  Open 
the  valve  ^,  very  slowly  and  cautiously;  the  oxygen  will  then 


206  ARTIFICIAL  ANESTHESIA. 

flow  through  the  tube  F,  to  the  gas-bag  C.  When  the  bag  is 
filled,  the  valve  B,  may  be  closed  and  the  apparatus  is  ready  for 
use.  If  the  valve  B.  is  opened  too  much,  a  portion  of  the  gas 
may  rush  by  the  bag,  and  forcing  its  way  through  the  water,  be 
lost;  to  correct  this  it  is  only  necessary  to  partially  close  valve 
B.  In  administering  the  oxygen  by  the  lungs,  the  usual  prac- 
tice is  to  cause  the  patient  to  inhale  very  slowly  from  three  to 
four  gallons. 

Cylinders  are  furnished  containing  forty  or  one  hundred 
gallons  of  pure  Oxygen  Gas,  or  a  mixture  of  Oxygen  and 
Nitrous  Oxide  in  definite  proportions  respectively,  of  20  per 
cent,  and  40  per  cent,  of  Nitrous  Oxide. 

Cylinders  containing  inxre  Nitrous  Oxide  Gas  are  painted 
black;  those  containing  pure  Oxygen,  are  painted  rerf.  Oxygen 
cylinders  containing  twenty  per  cent,  of  Nitrous  Oxide,  are  paint- 
ed black,  one-fifth  of  their  length,  the  remainder  red  ;  those  con- 
taining forty  per  cent,  of  Nitrous  Oxide,  are  painted  black  two- 
fifths  of  their  length,  the  remainder  red. 

Administration  of  oxygen  by  enema  is  a  later  suggestion.  In 
some  diseases,  this  method  is  more  effective  in  results  than  when 
the  gas  is  administered  by  inhalation,  and  it  promises  a  consid- 
erable range  of  usefulness. 

The  cut  (Plate  19)  shows  the  enema  apparatus,  as  set  up  for 
use, — the  receiver  C,  having  been  previously  filled  with  oxygen, 
— in  which  A,  represents  the  cylinder ;  B,  the  gas-valve  ;  C,  the 
gas-receiver;  D,  the  wash-bottle  used  to  moisten  and  warm  the 
gas ;  E,  a  syringe-point ;  F,  a  water-tank  or  reservoir,  provided 
with  a  measuring  gauge  on  its  side ;  G,  a  stopcock  on  the  gas-re- 
ceiver; H,  a  rubber  tube,  serving  a  double  purpose  as  below 
described.  To  put  a  new  apparatus  in  use,  place  it  as  shown  in 
the  cut,  the  vertical  distance  between  the  supports  for  the  two 
metal  cans  being  about  22  inches.  Proceed  first  to  expel  the 
air  from  the  gas-receiver  C,  then  to  fill  it  with  oxygen  from 
the  gas-cylinder.  To  accomplish  this,  disconnect  the  tube  H 
from  the  cock  G,  and  having  opened  G,  pour  water  slowly  into 
F,  allowing  it  to  pass  through  I  into  C,  until  it  appears  at  G. 
Close  G,  and  continue  the  operation  until  the  surface  of  the 
water  rises  in  F,  to  Fig.  5,  on  the  gauge.     Place  the  yoke  con- 


OXYGEN    BY    ENEMA. 


207 


nection  over  the  valve  B,  on  the  gas-cylinder,  as  shown  in  the 
cut,  being  careful  to  put  the  leather  washer  in  its  proper  place 
about  the  gas-valve  opening.  Eeconnect  the  rubber  tube  H,  to 
G,  and  change  its  upper  end  from  the  wash-bottle  D,  to  the  gas- 
yoke.     Open  G,  full,  and  then  very  slowly  and  cautiously  open 

Plate  19. 


ENEMA  APPARATUS. 


B ;  this  will  allow  the  gas  to  pass  to  the  receiver  C,  and  drive 
the  water  to  the  elevated  reservoir  F,  Keep  the  valve  B,  nearly 
closed  and  under  careful  control  until  the  surface  of  the  water 
rises  in  F,  to  say  Fig.  1,  on  the  gauge,  when  it  may  be  closed 


208  ARTIFICIAL   ANESTHESIA. 

entirely,  as  the  water  will  continue  to  rise  after  the  gas  is  shut 
off.  As  soon  as  the  water  in  F,  ceases  to  rise,  close  G,  and  re- 
place the  tube  H,  in  the  position  shown  in  the  cut.  The  wash- 
bottle  D  should  now  be  half  filled  with  water  at  a  temperature 
of  110°  to  120°  Fahrenheit,  when  the  syriuge-point  E,  may  be 
inserted  in  the  rectum  of  the  patient  and  the  stop-cock  G 
slowly  opened.  The  oxygen  will  now  pass  through  the  warm 
water  to  the  patient,  and  when  the  surface  of  the  water  in 
the  reservoir  has  fallen  one  division  on  the  gauge,  one  quart 
will  have  been  administered,  which  is  the  quantity  usually 
given. 

The  flow  of  gas  may  be  stopped  by  closing  G,  and  the  gas  re- 
maining in  0,  retained;  it  being  necessary  to  refill  it  from  the 
cylinder  only  when  the  water  in  F,  has  fallen  to  Fig.  5,  on  the 
gauge.  As  the  surface  of  the  water  in  F,  falls,  it  may  be  advis- 
able to  set  the  reservoir  a  few  inches  higher,  to  obtain  the  re- 
quisite pressure  on  the  gas. 

Caution. — Special  care  is  required  in  beginning  the  adminis- 
tration of  oxygen  by  enema,  to  avoid  the  distress  caused  by  a  too 
rapid  flow  of  the  gas.  It  should  be  permitted  to  bubble  through 
the  water  in  the  bottle  very  slowly.  This  is  accomplished  by 
opening  the  stopcock  G,  very  gradually,  so  as  to  permit  only  a 
gentle  flow.     After  a  few  administrations,  no  pain  or  discomfort 

will  be  experienced. 

Oxyg^en  Gas. 

The  best  formula  for  preparing  oxygen  gas  for  practical  pur- 
poses, is  that  suggested  by  Fresenius  :  * 

R      P.  Potass,  chloral.,  Squibb's  or  Merk's  ....  lbs.  iv. 
P.  Manganesii  dioxid.,  best  imported  cryst.  .    .    lb.    i. 

P.  Ferri  carb.  prec zij. 

M. 
S. — To  be  well  mixed  and  triturated,  avoiding  violent  friction, 
lest  an  explosion  be  produced.  (With  reasonable  care,  the  liability 
to  this  accident  is  very  slight.)  The  prepared  material  should  be 
throughly  desiccated,  by  being  exposed  to  moderate  heat  in  an  open 
oven,  or  by  means  of  a  chemical  drying-chamber.  Store  in  any  re- 
ceptacle which  will  protect  it  from  moisture,  until  wanted  for  use. 

*  Bulletin  Practical  Results.     The  American  Oxygen  Association,  New  York. 


OXYGEN   GAS.  209 

The  best  retorts  are  made  either  of  brass  or  iron.  Copper 
oxidizes  more  rapidly,  besides  requiring  an  increased  degree  of 
heat.  The  conical  shape,  with  broad  bottom,  is  much  superior 
to  the  old-fashioned  flat  or  pear-shape,  the  evolution  of  gas 
from  the  latter  being  tumultuous,  and  less  under  control.  For 
making  more  than  thirty  or  forty  gallons  at  an  effort,  the  cylin- 
drical form  of  retort  is  still  more  preferable.  With  the  latter 
form,  the  process  is  entirely  under  control. 

"  In  opposing  the  views  of  those  who  believe  the  inhalation 
of  oxygen  to  be  dangerous  on  account  of  its  activity  in  chemi- 
cal combustion,  Demarquay,  states,  that  he,  himself,  his  friends, 
his  pupils,  and  large  numbers  of  his  patients,  have  inhaled  from 
ten  to  thirty  litres  (2J  to  10  gallons)  of  the  gas  at  a  time,  with- 
out experiencing  the  slightest  injury.  ...  Its  effect  on  the 
various  sensations  is  but  slightly  marked,  except  in  case  of  nerv- 
ous subjects." — Dr.  J.  Solis- Cohen. 

"  Demarquay  refers  much  of  the  objectionable  results,  for- 
merly attributed  to  oxygen,  to  certain  impurities  with  which  it 
became  contaminated  in  the  methods  of  preparation,  an  objec- 
tion to  its  use,  which  no  longer  exists  under  the  improved 
methods  of  obtaining  the  gas  in  its  pure  state." — Idem. 

"  Demarquay,  as  the  result  of  his  extensive  clinical  experi- 
ence, recommends  inhalations  of  oxygen  in  all  chronic  affec- 
tions associated  with  debility,  dyspepsia  and  anaemia,  the  enu- 
meration of  which  it  is  useless  to  repeat." — Idem. 

Both  in  the  preparation  of  debilitated  patients  to  undergo 
serious  operations,  and  in  the  treatment  of  protracted  suppura- 
tion, and  other  depressing  conditions  after  operation,  inhala- 
tions of  oxygen  were  found  of  great  efficacy." — Idem. 

"Pure  oxygen,  contrary  to  the  general  belief,  can  be  inhaled 
for  several  hours  without  being  detrimental  to  health  ;  its  ac- 
tion is  antagonistic  to  that  of  chloroform ;  it  is  a  powerful 
remedy  for  the  disagreeable  accidents  arising  from  chloroform 
and  other  anaesthetics ;  and  in  asphyxia,  from  poisonous  gases 
— as,  for  instance,  from  carbonic  acid — it  exercises,  likewise,  a 
beneficial  influence.  .  .  . 

"  Every  patient  awakening  from  a  chloroform  narcosis  should 
inhale  oxygen,  in  order  to  rid  himself  of  headache  and  other  in- 


210  ARTIFICIAL  ANESTHESIA. 

conveniences,  following  the  administration  of  that  ansesthetic." 
— Diicroij. 

"  A  young  man  attached  to  the  laboratory  of  the  New  York 
Medical  College  became  asphyxiated  from  the  inhalation  of  the 
vapor  of  chloroform ;  and  so  far  had  its  effects  been  carried  that 
he  became  pulseless,  and  all  hopes  of  his  resuscitation  aban- 
doned ;  and  as  all  the  usually  recommended  remedies  had  been 
tried  without  success,  nothing  but  the  death  of  the  young  man 
was  looked  for,  when  I  proposed,  as  a  dernier  resort,  the  appli- 
cation of  pure  oxygen  gas,  as  the  only  chance  by  which  resusci- 
tation could  be  brought  about ;  but  at  the  time,  the  proposal 
met  with  opposition  from  the  medical  men  present,  who  were 
anxiously  watching  what  seemed  to  be  the  expiring  efforts  of  the 
poor  boy,  expecting  each  moment  to  be  his  last.  Having,  how- 
ever, consented,  the  gas  had  not  been  more  than  a  few  seconds 
applied  to  his  nostrils,  when  he  who  was  apparently  beyond 
the  help  of  human  skill,  and  absolutely  in  articulo  mortis,  arose 
and  placed  himself  upon  a  chair,  proving  most  conclusively 
how  correct  I  was  in  proposing  the  application  of  oxygen  gas 
as  a  remedy  against  the  deleterious  effects  of  chloroform  as  an 
ansesthetic." — Dr.  Simeon  Abrahams. 

"  Dr.  Const,  Paul  reports  a  case  of  opium  poisoning  in  which 
the  gas  was  successfully  used  after  atropia  had  failed,  and  when 
the  patient  appeared  to  be  dying,  and  another  in  which  it  was 
successfully  employed  in  narcosis  from  charcoal  gas.'' — Ran- 
kin's Abstract,  XL  VIII. 

"Sieveking  reports  two  cases  of  restoration  by  oxygen,  in 
poisoning  by  carbon." — The  Lancet,  1869. 

"  It  is  my  firm  conviction  that  oxygen  will  do  in  croup  all 
that  can  be  done  by  tracheotomy,  although  neither  the  one  nor 
the  other  is  competent  to  undo  the  mischief  wrought  by  severe 
and  prostrated  dyspnoea." — Dr.  Andrew  H.  Smith. 

"  Biegel  believes  that  in  children  predisposed  to  phthisis,  the 
inhalation  of  oxygen  would  delay  or  even  prevent  the  outbreak 
of  the  disease ;  and  that  even  after  their  development  of  the 
affection,  inhalations  of  the  same  sometimes  render  astonishing 
services." — J.  Solis- Cohen. 

"  In  one  case  of  undoubted  incipient  phthisis,  the  inhalation 


OXYGEN   GAS.  211 

of  oxygen  certainly  warded  off  the  threatened  disease,  and  gave 
the  patient  renewed  vigor,  as  evinced  by  increase  in  nutrition, 
renewal  of  vital  buoyancy,  and  restored  powers  of  physical  en- 
durance."— Idem. 

"  It  has  been  used  with  more  or  less  success  in  the  treatment 
of  many  constitutional  diseases:  diabetes,  albuminuria,  syph- 
ilis, scrofula,  scorbutus,  gout,  boils  and  carbuncles,  torpid  and 
gangrenous  ulcers,  neuralgias,  epilepsy,  paralysis,  atonic  and 
fatty  diseases  of  the  heart,  dyspepsia,  in  valvular  cardiac  dis- 
ease, and  also  in  pneumonia,  capillary  bronchitis  and  some 
other  acute  affections." — Idem. 

"  Dr.  Lasukewitch,  examining  the  physiological  action  of 
oxygen,  insists  upon  the  following  points  : 

"  1st.  Pure  oxygen  is  absorbed  by  the  blood  in  far  greater 
proportion  than  the  oxygen  of  the  air. 

"  2d.  Inhalations  of  pure  oxygen  produce  an  augmentation  of 
the  daily  excretion  of  urea. 

"  3d.  At  the  same  time  they  augment  the  temperature  of  the 
body  from  0.2°  to  0.9°  C.  (0.36°  to  1.6°  F.) 

"  4th.  They  modify  the  pulse  by  increasing  its  fulness. 

"  5th.  They  diminish  reflex  activities. 

"  6th.  They  augment  the  secretion  of  urine. 

"Passing  to  the  therapeutic  applications  of  oxygen,  the 
author  sets  forth  that  he  has  had  eight  successes  and  six 
failures. 

"  Oxygen  shows  itself  inefficient  in  paralysis  agitans,  in  men- 
ingeal myelitis,  in  ataxia,  in  chorea.  It  has  given  excellent  re- 
sults in  the  following  cases  : 

"  1.  In  a  grave  case  of  hystero-epilepsy  the  inhalations  in- 
variably arrested  the  onset,  produced  calm  sleep,  ameliorated 
the  general  state,  and  finally,  after  two  weeks  of  treatment, 
brought  about  a  cure,  either  permanent  or  at  least  temporary. 

"  2.  In  a  case  of  hysterical  hemiplegia,  inhalations  for  a 
single  minute  succeeded  in  dispersing  the  symptoms. 

"3.  In  a  severe  case  of  hysterical  convulsions,  the  hysterical 
excitement  following  a  severe  moral  [mental  ?]  shock,  inhala- 
tions of  oxygen  lasting  one  minute,  and  frequently  repeated 
through  the  day,  have  not  only  arrested  the  attacks,  but  have 
resulted  in  complete  cure. 


212  ARTIFICIAL   ANAESTHESIA. 

"  4.  In  a  case  of  severe  spasmodic  cough  at  the  beginning  of 
pregnancy,  the  inhahitions  immediately  arrested  the  cough,  and 
cured  the  patient  in  the  course  of  two  days. 

"  5.  In  a  case  of  hydrophobia,  the  inhalations  very  much 
modified  the  paroxysms,  but  did  not  succeed  in  averting  a  fatal 
termination. 

"  6.  In  a  case  of  syphilitic  affection  of  the  marrow,  with  ex- 
aggerated muscular  excitability,  all  the  symptoms  subsided 
after  three  days'  treatment. 

"  7.  In  a  case  of  bronchial  asthma  recurring  with  each  men- 
strual epoch,  oxygen  very  happily  modified  the  trouble. 

"  In  locomotor  ataxia,  Uspensky,  obtained  diminution  of  the 
pains,  and  improvement  in  co-ordination. 

"  In  pleuritis,  Afanasieff,  has  experienced  two  successes  with 
oxygen. 

"  In  the  inveterate  vomiting  of  pregnancy,  Tschaudnowsky 
has  obtained  excellent  results. 

"  In  bacillary  phthisis,  Albrecht,  has  employed  inhalations  of 
oxygen,  and  has  obtained  an  augmentation  of  body-weight,  and 
a  diminution  of  dyspncea. 

"In  Asiatic  cholera,  Tronchin,  has  used  oxygen  inhalations, 
and  has  noted  a  marked  and  constant  betterment  of  the  general 
state  of  the  pulse." — La  Therapeutique  Med.  et  Chirurg.,  Paris, 
1887. 

"  Dr.  Loyssel,  has  experimented  with  pure  oxygen,  and  from 
it  has  obtained  very  good  results.     He  concludes  : 

"  1st.  That  in  certain  poisonings,  such  as  those  by  chloroform, 
ether,  opium,  sulphuretted  hydrogen,  carbon  dioxide,  cyanhy- 
dric  acid,  oxygen  constitutes  the  only  means  of  recalling  the 
patient  to  life,  when  all  else  has  failed. 

"2d.  That  its  presence  in  the  operating  room  is  certain  pro- 
tection against  fatal  accidents  from  the  use  of  antesthetics. 

"  3d.  That  it  succeeds  equally  well  in  asphyxia,  caused  by 
strangulation,  by  immersion,  by  toxic  gases,  etc.,  as  well  as  with 
the  new-born,  in  condition  of  apparent  death. 

"  4lh.  Life  can  almost,  wiih  certainty,  be  maintained  in  all 
cases  where  respiration  has  not  entirely  ceased,  even  if  there 
are  long  intervals  between  the  inspiratory  efforts. 


OXYGEN   GAS.  213 

"5th.  If  the  respiratory  and  circulatory  functions  have  been 
completely  arrested  for  a  short  time,  they  may  be  re-established 
by  means  of  oxygen,  which  it  is  necessary  to  administer  with 
perseverance,  even  when  it  is  believed  that  all  eflforts  will  be 
useless.  There  are  reported  many  cases  of  drowned  persons, 
and  of  children  apparently  dead,  who  have  been  saved,  thanks 
to  persistence  in  administering  oxygen. 

"6th.  Oxygen  may  be  inhaled  in  notable  quantity  without 
the  least  danger." 

"Holstein,  affirms,  that  oxygen  diminishes  or  hinders  in 
marked  manner  the  exaggeration  of  the  reflexes." 

"  Favr,  (Vratch,  No.  13,  1885,)  has  published  two  cases  of 
puerperal  eclampsia,  where  oxygen  has  been  inhaled  with  com- 
plete success." — La  Therapeutique,  1887. 

"  Oxygenated  Water  occupies  the  third  rank  in  the  list  of  an- 
tiseptics, according  to  Miguel ;  the  binoxide  of  mercury  and 
the  iodide  of  silver  alone  being  more  active.  As  this  (oxygen- 
ated water)  is  neither  irritant  nor  toxic,  it  can  replace  in  sur- 
gery, those  agents  which  present  these  objectionable  prop- 
erties. 

"  Dugardin  Beaumetz,  employed  it  with  success  internally  in 
grave  cases  of  anorexia. 

"  Daj'^ton,  who  has  experimented  with  peroxide  of  hydrogen, 
concludes,  that  it  is  an  energetic  deodorant,  a  powerful  antisep- 
tic ;  that  it  is  indicated  in  a  vast  category  of  maladies  where 
the  mucous  membranes  are  affected.  Employed  iu  irrigations, 
it  is  superior  to  all  other  substances. 

"At  the  present  day  there  is  a  tendency  to  attribute  to  the 
presence  of  peroxide  of  hydrogen  in  the  air,  the  immunity  from 
pulmonary  affections  enjoyed  by  persons  dwelling  in  the  vicin- 
ity of  pine  forests." — The  Medical  Age. 


PAET  THIRD. 

ALCOHOL,  U.  S. 


CHAPTEE    XIII. 


Alcohol,  different  Kinds — The  Alcohol  recognized  by  U.  S.  Pharma- 
copoeia— Absolute  and  Dilute  Alcohols — The  Alcohol  in  Whiskey, 
Wine  and  Brandy — Amylic  Alcohol — The  Toxic  Action  of  Alco- 
hol— In  Moderate  Doses  the  Action  of  Alcohol  on  the  Heart — 
Heat-producing  and  Waste-preventing  Action  of  Alcohol — Physi- 
ological Action  of  Alcohol — Alcohol  as  an  Anaesthetic — Views  of 
Richardson,  Link  and  Others — Toxicology — Treatment  of  Acute 
Alcoholic  Poisoning. 

There  are  at  least  a  dozen  different  kinds  of  alcohol.  Nine 
are  liquid,  as  methyl  alcohol,  ethyl  and  amyl,  etc. ;  the  other  three 
alcohols  are  not  liquid,  being  waxy,  such  as  melyssyl,  etc. 

The  U.  S.  Pha,rmacopceia,  recognizes  alcohol  containing  94 
per  cent,  of  absolute  alcohol,  and  having  the  specific  gravity 
of  0.820,  and  alcohol  dilutum,  (dilute  alcohol),  containing  53 
per  cent,  of  alcohol,  and  having  the  specific  gravity  of  0.928. 

There  is  another  alcohol  which  is  termed  absolute,  and 
should  be  free  from  water,  being  very  volatile,  boiling  at 
172°  F.,  not  congealed  by  a  cold  of  166°  F.,  and  having  the 
specific  gravity  of  0.796. 

This  alcohol  is  a  chemical  agent,  producing  cold  by  its 
evaporation,  and  acting  powerfully  on  the  peripheral  motor 
nerves  and  the  skin,  as  a  local  ansesthetic.  In  aural  surgery 
it  acts  upon  polypi,  removing  their  watery  constituents,  and 
drying  them  up. 

Alcohol  is  found  to  be  the  active  agent  in  the  oflBcinal  spiritus 
2U 


PHYSIOLOGICAL   ACTION.  215 

frumenti,  or  whiskey,  and  spiritus  vini  gallici,  or  brandy,  which 
are  obtained,  respectively,  by  the  distillation  of  fermented 
grain,  and  of  fermented  grapes,  and  should  contain  from  48  to 
56  per  cent,  of  absolute  alcohol. 

Another  alcohol  which  is  mostly  used  in  this  country,  and 
European  countries  for  adulterating,  and  contains  much  amy- 
lic  alcohol,  is  made  from  Indian  corn,  potatoes,  beets,  wood, 
etc.  It  has  a  burning,  acrid  taste,  an  unpleasant  odor,  and  is 
oily.  It  is  of  a  dark  brown  color ;  but  this  is  removed  by  fil- 
tering through  lime,  charcoal  and  alum. 

Physiologrical  Action. 

It  has  long  been  recognized  that  when  persons  are  under 
the  controlling  influence  of  alcohol,  either  in  the  form  of  wine, 
gin,  whiskey  or  brandy,  they  may  be  cut,  bruised,  and  bones 
broken,  without  expressing  or  experiencing  much  or  any  pain. 
These  various  agents  were  employed,  as  we  have  before  stated, 
long  before  any  true  anaesthetic  was  discovered.  Whiskey  is 
still  quite  common  in  the  hands  of  our  railroad  surgeons,  and 
was  and  is  resorted  to  alone,  or  in  conjunction  with  chloro- 
form. 

When  alcohol  is  inhaled,  its  effects  are  developed  in  four 
distinct  stages : 

First  Stage. — There  is  excitement,  flushing  of  the  body  and 
dilatation  of  the  pupils ;  after  a  time  there  follows  languor, 
and  the  muscular  movements  become  irregular. 

Second  Stage. — Muscular  prostration  and  labored  breathing, 
attended  by  deep  sighing  movements  and  rolling  over  of  the 
body. 

Third  Stage. — Complete  insensibility  to  pain,  with  uncon- 
sciousness to  all  external  objects,  with  inability  to  exert  any 
voluntary  muscular  power.  The  breathing  now  becomes  em- 
barrassed, and  blowing,  with  bronchial  rales,  due  to  the  pas- 
sage of  air  through  fluid  that  has  accumulated  in  the  finer 
bronchial  passages.  The  heart  and  lungs,  however,  even  in 
this  stage,  retain  their  functions,  and  therefore  recovery  will 
take  place,  if  the  conditions  for  it  be  favorable.  Also,  if  the 
body  be  touched  or  irritated  in  parts,  there  will  be  a  response 


216  ARTIFICIAL   ANAESTHESIA. 

of  motion,  not  from  any  knowledge  or  consciousness,  but  from 
reflex  action.  During  all  the3e  stages  there  is  no  violent  con- 
vulsive action,  but,  step  by  step,  a  reduction  of  temperature ; 
80  at  last,  the  loss  of  heat  will  become  dangerous,  for  the  cool 
body  cannot  throw  off  the  water  freely,  and  therefore  fluid 
collects  in  the  lungs,  and  there  is  a  risk  of  suffocation,  as  from 
drowning.  If  the  administration  of  the  methylic  spirit  be 
continued,  when  the  third  degree  has  been  reached,  there  is  a 
fourth  stage,  which  is  that  of  death.  The  two  remaining  ner- 
vous centres,  which  feed  the  heart  and  respiration,  cease 
simultaneously  to  act,  and  all  motion  is  over.  If,  however, 
after  the  third  stage  of  insensibility,  the  administration  of  the 
spirit  be  stopped,  recovery  from  the  insensibility  and  prostra- 
tion will  invariably  take  place,  on  one  condition, — that  the  body 
be  kept  warm  for  seven  hours.* 

Alcohol  as  an  Anaestlieticf 

In  our  "  Manual  of  Anaesthetic  Agents,''  first  edition,  published 
in  March,  1878,  on  p.  18,  it  is  stated  that  Dr.  John  Link,  had 
long  employed  alcohol  in  the  form  of  whiskey  as  an  anaesthetic, 
alone,  or  in  conjunction  with  chloroform,  in  numerous  minor 
operations;  but  up  to  April,  1876,  he  had  not  tried  it  in  a 
capital  operation.  He  further  stated  that  he  should  depend 
upon  it  exclusively  in  his  next  amputation  of  a  limb.  This, 
he  states,  in  the  pamphlet  before  us,  did  not  occur  in  a  satisfac- 
tory way  until  1880.  Up  to  this  time  he  administered  whiskey 
to  the  amount  of  from  fourteen  to  eighteen  ounces,  or  two 
ounces,  in  proportion  to  tolerance  of  the  patient,  at  intervals  of 
from  two  to  five  minutes,  and  chloroform  to  the  extent  of  a 
few  inspirations. 

In  his  first  case,  he  reported,  a  great  shock  was  sustained  in 
a  railroad  accident,  by  a  brakeman,  on  the  Indianapolis  &  St- 
Louis  Railroad ;  whiskey  alone  was  given.  The  amputation 
was   down   near    the   hip ;   also    an    operation    on    the  foot, 

*  Kichardson. 

t  Pamphlet  of  8  pages.  Prepared  for  the  International  Medical  Congress.  By 
John  E.  Link,  M.D.,  Terra  Haute,  Ind.,  Chief  Surgeon  of  the  Vandalia  U.  E.,  etc., 
etc.,  etc. 


ALCOHOL   AS   AN   ANJilSTHETIC.  217 

througti  the  metatarsal  bones.  The  patient  asked  for  water, 
and  in  other  respects  seemed  rational  during  the  operation,  but 
died  soon  after  from  the  shock.  He  then  reports  four  cases, 
with  details  of  temperature,  pulse,  etc., — amputation  of  right 
arm,  right  foot,  secondary  of  two  left  legs.  He  states  these 
are  given  in  detail  as  typical  cases.  If  left  to  choose  between 
whiskey  and  chloroform,  alcohol  would  be  his  preference,  ad- 
ministered rapidly,  preserving  a  more  normal  or  physiological 
condition  of  the  system,  than  either  chloroform  or  ether. 

There  is  less  drunkenness  at  the  same  stage  of  insensibility 
to  pain  with  the  former,  than  with  the  latter. 

With  alcohol  we  have  hypersemia  of  the  base  of  the  brain, 
as  evidenced  by  the  flushed  face,  and  fulness  of  the  features 
about  the  eyes,  mouth  and  the  lips,  etc.  His  views  are  that  it 
has  a  counteracting  influence  against  shock,  ansemia  of  the 
brain,  from  loss  of  blood,  etc. 

On  page  8,  Dr.  Link,  defends  himself  against  the  charge 
that  such  administration  of  alcohol  leads  to  tippling  and 
drunkenness.  He  knew  of  no  one  case  where  such  had  been 
the  result,  and,  on  the  contrary,  he  might  cite  many  instances 
where  a  repugnance  and  distaste  for  whiskey  had  been  the  re- 
sult, even  in  those  where  an  appetite  for  it  existed  previously, 
the  very  smell  of  whiskey,  being  associated  with  the  operation 
and  suffering. 

Desiring  to  have  the  opinion  of  a  gentleman  who  is,  and  has 
been  for  many  years,  one  of  the  surgeons  to  one  of  the  most 
extensive  railroad  companies  in  the  United  States,  T  submitted 
Dr.  Link's  pamphlet  for  his  opinion,  which  we  now  publish, 
as  the  matter  is  of  great  practical  importance  : 

"  Huntingdon,  Pa.,  November  21,  1887. 
' '  My  Dear  Doctor  : 

"When  in  the  city  a  few  weeks  ago,  I  promised  to  read  the  report 
of  Dr.  Link  on  '  Alcohol  as  an  Anesthetic,'  and  write  you  my  ex- 
perience with  it.  The  promise  I  will  try  to  redeem  this  afternoon, 
knowing  full  well  that  all  I  may  say,  will  throw  no  new  light  on  the 
subject. 

"  In  regard  to  the  report  of  Dr.  Link,  I  must  say  that  I  cannot 
fully  endorse  his  ideas,  for  the  reason  that  he  gives  credit  to  the 
10 


218  ARTIFICIAL  ANAESTHESIA. 

'Alcohol,'  which,  in  my  opinion,  at  least,  is  partly  due  to  the 
chloroform. 

"  Before  administering  chloroform  to  a  patient  I  invariably  give  2 
to  3  oz.  whiskey,  with  from  J  to  J  gr.  morphia,  place  the  subject 
on  the  table  (in  case  of  amputation),  and  see  that  all  clothing  is 
loose  and  the  patient's  head  low  ;  then  on  a  towel  or  large  napkin, 
folded  in  4  to  6  plies,  I  pour  on  about  ^ss  chloroform,  and  allow  the 
patient  to  inhale  it  slowly  at  first,  adding  ^ss  from  time  to  time,  as 
required,  until  completely  under  its  influence.  In  this  way  it  is 
seldom  that  more  than  ^^ss  is  required  in  an  ordinary  amputation. 

''  If  the  patient  does  not  go  under  the  influence  rapidly  enough,  I 
place  my  open  hand  over  the  towel,  and  exclude  the  air  for  a  few 
inhalations,  which  always  has  the  des^ired  eflFect,  when  the  hand 
should  be  removed.  D.  H.    Miller,  M.D." 

The  late  Valentine  Mott,  in  his  essay  on  "  !Pain  and  Anaes- 
thetics," objects  to  those  agents  which  are  apt  to  disturb  the 
stomach,  and  reports  the  following  case : 

"I  well  remember  a  case  of  amputation  of  the  thigh  which  oc- 
curred a  few  years  since  in  my  own  practice,  where  the  attending 
physician,  notwithstanding  repeated  cautions,  administered  brandy 
to  the  patient  so  freely  as  to  induce  vomiting,  thus  interfering  with 
the  continuance  of  the  reaction,  and  inducing  a  fatal  result.  It  was 
an  ertensive  cannon  shot  of  the  knee-joint,  and  the  operation  was 
performed  on  the  third  day  from  the  injury,  before  the  collapse  had 
sufficiently  passed  off." 

These  various  alcohols  have  all  a  toxic  action  when  given 
in  sufficiently  large  doses.  The  general  effect  they  produce  on 
the  organism  is  paralysis,  affecting  the  nerve-centres  in  the  in- 
verse order  of  their  development.  Their  lethal  power  and 
the  symptoms  they  produce  are  modified  by  the  physical 
characters  and  the  quantity  administered. 

Yet,  it  has  been  found  that  in  moderate  doses,  alcohol  caused 
great  increase  in  the  rate  and  force  of  the  cardiac  beat,  and  cor- 
responding rise  of  the  arterial  pressure,  and  that  these  phenome- 
na were  not  affected  by  previous  division  of  the  pneumo-gastrics, 
of  the  accelerators  or  of  the  spinal  cord.  There  is  also,  in 
these  small  doses,  a  sensation  of  warmth,  and  an  increase  of 
heat,  while  in  very  large    doses  there  is   a  fall  of  tempera- 


STRYCHNINE   IN   ALCOHOLISM.  219 

ture,  from  an  increase  of  oxygen  consumed  and  of  carbonic 
acid  eliminated.  The  exhibition  of  alcohol  has  been  found  to 
lessen  the  excretion  of  urea  or  tissue  waste,  while  it  increased 
bodily  weight.  Alcohol  is  a  most  valuable  remedy  in  typhoid 
fever  and  diphtheria. 

Toxicolog-y. 

Cases  of  acute  alcoholic  poisoning  occur  during  every  few 
months  by  persons  drinking  very  large  quantities,  and  more 
especially  young  persons.  The  treatment  consists  in  the  evacu- 
ation of  the  stomach,  keeping  the  body  warm,  and  the  uae  of 
the  alternate  hot  and  cold  water  bag  of  Chapman,  while  keep- 
ing the  person  in  active  motion,  by  rubbing  six  or  seven  hours. 

Strychnine  in  Alcoholism. 

From  experiments,  we  feel  justified  in  drawing  the  following 
conclusions :  1.  Strychnine  undoubtedly  neutralizes  the  in- 
toxicating and  narcotic  effects  of  alcohol.  2.  It  enables  large 
quantities  of  alcohol  (when  necessary)  to  be  taken  for  a  con- 
siderable stretch  of  time,  without  causing  the  usual  organic 
lesions  which  follow  the  use  of  alcohol  alone.  3.  There  are, 
however,  limits  beyond  which  the  alkaloid  itself  becomes  in- 
jurious to  the  organism.  4.  Therapeutically,  strychnine 
should  be  used  in  all  forms  of  alcoholism.  5,  It  may  be  re- 
garded as  a  powerful  prophylactic  against  alcoholism. 


220  ARTIFICIAL  ANjESTHESIA. 

CHAPTER    XIV. 

ETHER. 

Manufacture — Chemical  Reaction  and  Composition — Tests  of  Purity, 
Inflammability — Ether  Fortior — Dr.  Squibb's  Ether — Tin  or 
Glass  in  Preserving  Ether — Inflammability  of  Ether — Influence 
of  Ether  on  the  Brain  and  Pulse — The  Ordinary  Method  in  use 
for  the  Administration  of  Ether :  Towel,  Cone — Precautions  to 
be  employed  before  and  after  using  Ether,  and  Treatment  of 
Dangerous  Symptoms. 

Ethyl  Oxide,  Ethyl  Ether,  c'h'}^*  ^ 

This  body,  commonly  called  "  ether,''  is  manufactured  on  a 
large  scale  by  heating  a  mixture  of  strong  alcohol  and  concen- 
trated sulphuric  acid  to  140°.  The  reaction  takes  place  in 
two  stages;  in  the  first,  ethyl  sulphuric  acid  and  water  are 
formed : — 


H 


}o+g}so,=^f^}so,+|}o. 


The  ethyl  sulphuric  acid  acts  at  140°  upon  another  molecule 
of  alcohol ;  hydrogen  and  ethyl  change  places,  and  ether  and 
sulphuric  acid  are  formed : — 


C.H. 
H 


}sO.4°}|'>}0=H|so.+§If>}o. 


\ 


The  ether  and  the  water  produced  are  distilled  off,  whilst  the 
sulphuric  acid  remains  behind,  ready  to  convert  another  quan- 
tity of  alcohol  into  ether. 

The  Physical  and  Physiological  Properties  of  Ether. 

Ether  is  colorless,  very  volatile,  inflammable,  both  it  and  its 
vapor,  which  latter  is  twice  as  heavy  as  ordinary  air,  and  sinks 


TESTS   OF   PURITY   OF   ETHER.  221 

//  ^ 

(/  therefore  to  the  floor,  which  is  important  to  remember  when  a 

light  has  to  be  used,  or  a  heated  metal.  It  is  soluble  in  alco- 
hol ;  its  odor  is  garlic-like,  strong  and  pungent.  Its  taste  is 
hot,  slightly  soluble  in  water.  Ether  must  be  kept  in  the 
dark  and  in  well  and  carefully  prepared  tins  (see  reasons  by 
Dr.  Squibb).  When  in  ordinary  use,  keep  in  the  bottle  of  Dr. 
Eoberts  (Plate  21,  page  228);  for  if  kept  in  a  hot  place 
or  in  the  tropics,  it  is  apt  to  change  by  absorption  of  water, 
undergoing  decomposition  and  developing  acetic  acid,  making 
it  unfit  for  inhalation. 

The  following  are  some  of  the  methods  of  determining  if  the 
ether  is  pure :  * 

1.  Ether,  if  pure,  forms  a  clear  mixture  with  oil  of  copaiba; 
bat  if  it  contains  water  or  alcohol,  an  emulsion  will  result. 

2.  Water  is  detected  by  adding  tannin ;  for  when  water  is 
present,  the  mixture  becomes  syrupy,  while,  if  absent,  the 
powdered  tannin  remains  unchanged. 

3.  Alcohol,  if  present,  gives  a  red  stain  with  crystals  of 
fuchsine ;  it  also  increases  the  specific  gravity. 

4.  Acids  sulphuric  and  sulphurous  are  detected  by  the  pre- 
cipitates they  give  with  barium  chloride ;  also  an  acid  which 
produces  a  deep  red  color  upon  the  addition  of  an  iron  salt. 

6.  Fusel  oil  may  be  detected  by  leaving  a  greasy  stain  on 
paper. 

When  inhaled,  it  produces  a  burning  and  choking  sensation 
— in  some  almost  suffocation — from  the  vapor  uniting  with  the 
fluids.  If  inhaled  freely,  mixed  with  air,  it  produces  intoxication 
with  roaring  and  buzzing  in  the  ears,  varying  in  its  effects  upon 
different  individuals.  In  some  persons  it  causes  depression, 
with  weeping ;  others,  elevation  of  spirits,  indicated  by  shouting, 
laughing,  singing ;  others  disposed  to  fight  or  strut  about  de- 
claiming, imagining  themselves  upon  the  stage.  When  still 
semi-conscious,  there  is  a  feeling  as  if  one's  immediate  sur- 
roundings were  afar  off,  with  visions  and  illusions.  In  this 
first  stage  the  patients  will  open  their  eyes,  and  a  slight  noise 
or  loud  talking  will  arouse  them. 

^^  *  Buxton. 


w 


222  ARTIFICIAL   ANAESTHESIA. 

//  If  now  all  air  is  withdrawn,  and  the  patient  breathes  deeply  \ 
and  long,  it  brings  about  sooner  or  laier  the  second  stage  of 
complete  unconsciousnesa  or  ether  narcosis ;  but  still  there  is 
muscular  rigidity.  As  soon  as  this  passes  off,  the  complete 
ancesthetic  stage  takes  place,  when  the  patient  lies  quiet,  with 
slow  and  regular,  automatic  respiration,  and  the  arm,  when 
elevated,  will  fall  as  if  paralyzed,  and  the  eye,  if  touched,  will 
not  wink.  Now  and  then  we  have  a  slight  stertor  in  the 
breathing.  Now  is  the  time  for  operation  and  the  partial 
withdrawal  of  the  ether,  giving  the  patient  air  at  intervals, 
but  sufficient  ether  to  keep  him  fully  under  its  influence  by 
the  combined  vapor. 

Deep,  stertorous  respiration,  due  to  paresis  of  the  muscles 
of  the  palate,  should  be  the  signal  for  allowing  air  to  mix  with 
ether  vapor  or  for  the  entire  withdrawal  of  the  anaesthetic.  The 
usual  appearance  of  the  face  of  the  patient  during  etheriza- 
tion is  reddish,  lips  especially;  if  marked  pallor  and  lividity 
should  show  themselves,  indicating  failure  of  heart  action,  the 
ether  is  to  be  stopped  at  once,  and  the  feet  of  the  patient  ele- 
vated and  the  head  depressed  until  the  color  returns.  An- 
other important  sign  of  danger  is  what  is  termed  shallow 
breathing;  the  respiration,  from  being  slow  and  regular,  be- 
comes very  much  quickened,  and  then  becomes  slower  and 
slower  until  it  gradually  ceases  or  intermits  for  long  intervals. 
In  such  case,  stop  the  inhaler  and  admit  cold  air,  or  apply  the 
vapor  of  aqua  ammonia  to  the  nose ;  or  the  application  of  a 
wet  towel,  wrung  out  of  cold  water,  applied  to  the  uncovered 
chest  with  some  little  force,  will  generally  cause  the  patient  to 
make  a  sudden  gasp,  and  rouse  the  respiratory  function  to  ac- 
tion. If  these  measures  fail,  then  resort  must  be  had  to  arti- 
ficial respiration  and  the  prevention  of  great  reduction  of  heat, 
as  the  lungs  are  the  chief  eliminators,  the  kidneys  only  doing 
a  part,  and  yet  if  they  are  diseased,  it  is  apt  to  produce  great 
distress  and  may  be  the  cause  of  death. 

The  ordinary  method  in  use  of  the  administration  of  the  second 
discovered  ancesthetic,  namely,  washed  ether,  is  as  follows  : 

An  inhaler  is  made  by  folding  a  towel  into  a  large  cone,  or  i 
\\   bag,  and  then  placing  a  coarse  sponge,  wrung  out  of  hot  water,  , 


METHOD   OF   ETHER   ADMINISTRATION.  223 

(^      ia  its  apex.    Ether  is  then  poured  upon  it  from  a  bottle — about       m 
two  drachms  to  half  an  ounce  at  a  time — and  repeated,  when 
necessary,  by  removing  the  cone  from  the  patient's  mouth  to 
renew  the  supply  of  ether. 

The  lower  part  of  the  face,  mouth  and  nose,  are  covered  with 
the  cone,  so  as  to  exclude  most  of  the  air,  and  allow  the  patient 
to  fill  his  lungs,  with  more  or  less  diluted  ether  vapor,  giving 
it  slowly,  and  with  great  care.  After  a  time,  there  will  be  at- 
tempts to  struggle,  on  account  of  the  irritating  nature  of  the 
ether,  and  the  stimulating  action  of  the  drug,  which  are  to  be 
gently  but  firmly  restrained,  using  as  little  force  as  possible, 
and  only  one  or  two  inspirations  of  pure  air  allowed.  In  from 
three  minutes  to  three  and  a  half,  complete  quiescence  usually 
follows,  and  the  patient  passes  into  a  profound  state  of  insen- 
sibility. One  of  the  best  tests  of  the  patient  being  fully  under 
the  influence  ofthe  ether  is  when  the  conjunctival  surface  of  the 
eye  cau  be  touched  with  the  finger  without  producing  winking. 
If  the  face  becomes  livid  or  very  pale  or  gray  in  color,  or  the 
breathing  much  oppressed,  the  cone  is  lifted  entirely  away  for 
a  time,  until  these  conditions  disappear.  lu  delicate  persons, 
it  is  well  to  notice  any  unusual  slowness,  or  intermittence  of 
the  respiration  and  pulse.  The  second  test  is,  if  the  arm  be 
raised,  it  will  generally  fall,  as  if  paralyzed.  As  soon  as  com- 
plete anaesthesia  is  established,  if  it  is  a  prolonged  operation, 
the  cone  is  taken  off  the  face  at  intervals,  that  he  may  take 
a  few  inspirations  of  air,  keeping  up  the  condition  with  less 
ether. 

The  functions  of  the  cerebrum  or  brain  are  first  affected, 
before  those  of  other  portions  of  the  nervous  system.  After  a 
more  prolonged  inhalation,  the  anterior  or  motor  centres  soon 
fail  to  respond  to  mechanical  irritation,  yet  the  functions  of 
the  medulla  oblongata  are  performed. 

If  the  inhalation  of  ether  is  still  further  carried  on,  the 
sensory  and  finally  the  motor  functions  of  the  medulla  oblon- 
gata are  involved,  and  death  occurs  from  a  paralysis  of  the 
respiratory  centres  and  heart.     Louget  states,  that  he  found 
►  the  sensory  functions  abolished  very  early,  but  he  has  never 
\\failed  in  any  stage  of  the  narcosis  from  ether,  to  get  a  response      y/ 


224 


AETIFICIAL   ANESTHESIA. 


w 


from   the  anterior  part  of  the  cord,  by  employing  powerful 
galvanic  currents.  /y 

Pulse  Tracings  under  Etlier,  by  Morgan,  of  Dublin. 

riate  20— (Figs.  1-8). 


Fiff.  1. 


Fig.  2. 


Fig.  1  represents  the  pulse  of  a  female  patient,  aged  twenty- 
five,  who  had  been  confined  to  bed  for  five  months;  pulse 
writing  taken  before  etherization. 

Fig.  2  represents  it  during  its  full  influence.  It  will  be 
seen  that  the  heart  power  indication  was  rather  stronger 
during  etherization  than  before. 

Fig.  3. 


Another  instance  of  a  female,  aged  seventeen,  also  long 
confined  in  bed.    The  contrast  of  Fig.  3,  taken  before  ether- 
Fig.  4. 


ization,  and  of  Fig.  4,  during  profound  etheriz.ition,  is  notable  ; 


PULSE   TRACINGS    UNDER    ETHER. 


225 


the  elevation  of  the  pulse  line,  showing  the  stimulating  prop- 
erty of  the  ethereal  influence. 

Fi2.  5. 


Fig.  5  represents  the  excited  pulse  writujg  of  a  small  and 
nervous  female,  previous  to  etherization  and  operation. 

Fior.    6. 


Fig.  6  represents   the   pulse   writing    or   the   same   patient 

when  steadied  by  etherization.     The  contrast  is  remarkably 

favorable. 

Fig.  7. 


Fig.  7  represents  the  pulse  writing  ot  a  healthy  yuung  man 
of  twenty-two,  previous  to  operation  for  artificial  pupil — an 
affection  which  had  not  interfered  with  his  general  health. 

Fis.  8. 


Fig.  8  represents  the  same  wheu  taken  under  full  etheriz- 
ation, and  after  the  (iompletion  of  the  operation.  A  com- 
parison of  this  pulse  writing  with  that  of  the  natural  soft 
pulse,  will  be  ample  evidence  of  the  safety  of  etherization  in 
its  action  on  the  heart. 

10* 


226  ARTIFICIAL.   AN.?5STHESIA. 


/„ 


V 


Precautions  to  be  Employed  before  and  after  using: 
Ether  as. an  Anaesthetic. 

Ether  should  not  be  inhaled  immediately  after  a  full  meal ;  >^ 
indeed,  it  is  better  to  take  only  a  biscuit,  or  cracker,  and  a  glass 
of  wine  or  a  teaspoonful  of  brandy  and  water,  or  a  scruple  of 
bromide  of  potassium  in  water,  half  an  hour  before,  always 
avoiding  for  several  hours  previous  the  risk  and  annoyance 
of  a  full  stomach.  Nothing  like  solid  food  should  ever  be  al- 
lowed a  feeble  patient  before  inhalation,  for  twenty-four  hours. 
If  nourishment  is  necessary,  let  it  be  of  a  liquid  character,  like 
beef  tea,  as  solid  food,  not  digested,  has  been  the  cause  of  death, 
in  more  than  one  person. 

Perfect  quiet  should  be  enjoined  on  all  around  the  patient,  as 
noises,  or  even  loud  talking,  interfere  with  the  perfect  and 
rapid  action  of  the  anaesthetic.  Nothing  like  a  tight  band  or 
garment  should  prevent  the  free  action  of  the  throat,  chest,  or 
interfere  with  the  muscles  of  respiration.  False  teeth  should 
always  be  laid  aside  until  after  the  inhalation  is  over. 

An  examination  of  the  kidneys  should  always  be  made  be- 
fore using  ether,  as  they  are  the  active  agents  in  eliminating 
ether  from  the  blood,  and  if  they  are  unable  to  perform  this 
office,  and  if  the  skin  is  cold,  moist  and  inactive,  death  will 
supervene  by  accumulation  of  mucus  in  the  lungs,  or  congestion 
of  the  brain,  as  in  true  Bright's  disease  of  the  kidneys. 

Avoid  all  excitement  to  the  patient,  from  fear,  sight  of  instru- 
ments, too  many  spectators,  etc.,  all  of  which  tend  to  induce 
shock.  Have  appliances  for  resuscitation  at  hand,  and  plenty 
of  fresh  air  during  the  administration  of  the  ansesthetic.  la 
ether  the  respirations  and  heart  need  to  be  watched,  during 
and  after  anaesthesia,  and  also  prevent  the  reduction  of  tempera- 
ture by  hot  bottles  of  water,  etc.,  in  the  later  stages  of  narcosis 
from  ether. 

Dr.  Hobart  A.  Hare,  ( University  Medical  Magazine),  advises 
that  where  there  is  embarrassed  respiration,  or  temporary  sus- 
pension of  the  inspiratory  effort  during  the  administration  of 
ether,  that  in  place  of  resorting  to  flagellation  with  towels  wet 
with  cold  water,  a  little  ether  poured  upon  the  belly  will  cause, 
by  the  cold,  such  a  shock  as  to  produce  deep  inspiration. 


PEECAUTIONS   IN   THE   USE   OF    ETHER.  227 

^      The  boiling  point  of  pure  ether  is  95°  F.  ^ 

A  test-tube  filled  with  it  and  held  in  the  warm  hand,  should 
boil  on  the  addition  of  fragments  of  broken  glass.  In  hot 
countries,  like  India  and  our  Southern  States,  or  in  the  close 
wards  of  a  hospital,  if  preserved  in  imperfectly  stoppered  bot- 
tles, ether  will  absorb  oxygen,  and  forms  acetic  acid,  becoming 
impure,  and  is  therefore  unsuitable  for  inhalation.  Glass  is 
not  a  good  material  for  holding  ether,  because  it  is  so  fragile 
and  so  liable  to  accident,  and  ether,  when  spilled,  is  so  dan- 
gerously inflammable. 

Dr.  Squibb  has  seen  ether  take  fire  at  a  measured  distance 
of  fifteen  feet  between  the  source  of  the  escaping  vapor  and  the 
source  of  fire.  In  his  experience  of  thirty  years  he  could  re- 
call five  disastrous  fires,  involving  many  lives  and  serious  in- 
juries, and  over  a  million  dollars'  worth  of  property,  which  were 
traced  directly  to  the  breaking  of  bottles  of  ether.  No  method 
of  using  strong  ether  or  transporting  it  from  far  or  near  dis- 
tances can  be  compared  to  soldering  it  in  tin ;  it  is  thus  pre- 
served in  a  perfect  condition.  ':^^ 
-^i^v.  The  stud  is  as  easily  removed  as  a  cork  or  stopper,  aha 
leaves  a  smooth  neck  to  be  fitted  with  a  cork. 

Even  well-stoppered  glass  bottles  do  not  retain  the  ether  for- 
tior,  or  stronger  ether,  of  the  Pharmacopoeia  of  1882.  The  shelf 
or  closet  in  which  it  is  placed,  always  smells  quite  distinctly  of 
the  ether;  and  it  has  been  found,  by  accurately  weighing  a 
tray  containing  50  one-pound  bottles  well  stoppered,  so  as  not 
to  leak  perceptibly,  when  laid  on  their  sides  for  any  length  of 
time,  that  they  lost  at  the  rate  of  about  2  ounces  per  month, 
during  a  year.  Again,  a  leaky  stopper  cannot  be  detected,  unless 
the  liquid  escapes  at  a  rate  faster  than  it  can  evaporate. 

Corks  do  not  secure  ether  any  better,  nor  as  well,  as  glass 
stoppers,  because  if  the  ether  be  of  full  strength,  the  cork 
shrinks  and  becomes  too  small  for  the  bottle,  by  absorbing  all 
the  water  from  the  cork.  The  cork  is  very  good  for  temporary 
use. 


228 


ARTIFICIAL  ANESTHESIA. 


Tlie  Polyclinic  Never-Leaking  Ether  Bottle. 

Dr.  John  B.  Roberts,  of  this  city,  after  using,  with  varying 
degrees  of  dissalislattion,  tiu  cai;s  wiih   corks   and  ground- 
stoppered  bottles  i  n  cases,  fi- 
Plate  21.  nally  had  made  a  graduated 

white  ghiss  bottle,  with 
rubber  stopper  and  wire- 
spring  clamp,  like  that 
used  for  sealing  efferves- 
cent drinks.  These  bottles, 
being  made  of  strong  glass, 
are  not  broken  by  rolling 
in  the  bottom  of  the  car- 
riage, nor  by  being  carried 
in  a  bag  with  steel  instru- 
ments ;  no  leakage  is  possi- 
ble ;  the  stopper  cannot  be 
blown  out,  nor  is  it  liable 
to  stick  and  become  im- 
movable. The  bottle  is  always  quickly  and  easily  opened  by 
pressure  with  one  thumb  on  the  lever-like  clamp,  while  its 
shape  allows  the  ether  to  be  rapidly  and  completely  poured 
out.  Its  transparency  and  the  graduation  blown  in  the  glass, 
enable  the  surgeon  to  know  at  a  glance  how  much  ether  he  has 
on  hand.  A  cork,  perforated  by  two  small  tubes,  is  attached  by 
a  chain,  and  is  to  be  inserted,  when  the  aneesthetic  is  poured  out 
in  small  quantities.  Dr.  Roberts  uses  it  thus,  with  satisfaction, 
at  the  Polyclinic,  St.  Mary's  Hospital,  and  the  Pennsylvania 
Hospital.  If  the  rubber  stopper  becomes  worn  out  or  softened, 
it  can  easily  be  renewed,  without  changing  the  spring  clamp. 
These  ether  bottles  can  be  obtained  from  Mr.  Snowden. 


Inflanmiabilit.i 


Four  accidents  have  come  to  our  knowledge,  in  which  the 
ether  was  ignited,  and,  although  causing  no  actual  injury, 
produced  much  fear  and  confusion.     The  first,  was  where  a 


INFLAMMABILITY   OF   ETHER.  229 

bottle  of  ether  was  accidentally  broken  and  ignited,  while  Dr. 
William  Hunt  was  operating,  during  the  night,  at  the  Penn- 
sylvania Hospital.  The  second  occurred,  while  Dr.  William 
H.  Pancoast  was  applying  the  actual  cautery  to  a  patient  at 
the  Jefferson  College  Hospital  clinic,  during  the  day. 

In  a  letter  to  the  author  from  H.  C.  Yarrow,  A.  A.  Surgeon, 
U.  S.  A.,  he  states  that  a  case  of  ether  taking  fire  from  the 
galvanic  cautery  occurred  to  Dr.  Huntington,  Surgeon,  U.  S. 
A.,  and  himself  at  the  Soldiers'  Home,  Washington,  D.  C, 
during  an  operation  for  the  removal  of  a  cancerous  growth  on 
the  temporal  region  by  means  of  the  galvano-cautery.  The 
patient  being  under  the  influence  of  ether,  the  vapor  became 
ignited  by  contact  with  the  heated  platinum  wire.  No  injury 
resulted  beyond  a  slight  scorching  of  the  patient's  hair,  but 
the  accident  shows  the  necessity  for  great  care  in  the  use  of 
ether  operations  with  the  galvano-cautery. 

The  practical  safety  of  ether  vapor,  when  near  a  flame  or  a 
heated  wire,  is  doubtless,  partly  owing  to  the  fact  that  the  air 
cooled  by  its  evaporation  establishes  a  downward  current. 
This  is  due  to  the  greater  density  of  ether  vapor,  for  whilst  the 
ether  itself  has  a  specific  gravity  of  .728,  its  vapor  has  2.568 
for  its  specific  gravity  ;  and  this  fact  may  be  readily  noted  by 
observing  the  downward  currents  of  vapor  when  pouring  from 
one  bottle  to  another. 

The  ether  which  is  employed  in  Philadelphia  by  its  chier 
surgeons  in  private  practice,  and,  indeed,  throughout  the 
United  States,  is  that  manufactured  by  Dr.  E.  E.  Squibb,  of 
Brooklyn,  New  York,  but  the  objections  to  it  are,  that  it  is  of 
higher  price,  and  is  almost  free  from  water,  resembling  chlo- 
roform, therefore  the  more  dangerous  for  use  in  the  ordinary 
quantity;  it  is  also  more  apt  to  produce  irritation  if  used  too 
freely,  causing  cough  and  spasm.  This  may  be  obviated  by 
moistening  with  warm  water  the  sponge  in  the  paper  and  towel 
cone,  or  inhaling  apparatus,  or  by  diluting  the  vapor  before 
use  with  air. 

The  following  correspondence  between  the  writer  and  Dr. 
Squibb,  will  give  his  opinion  in  regard  to  the  character  of  the 
ether,  which  is  so  much  in  demand : 


230  ARTIFICIAL  ANESTHESIA. 

Phila.,  Feb.  7,  1881. 
Dr.  E.  R.  Squibb,  Brooklyn,  New  York. 

My  Dear  Doctor, — On  Wednesday  next,  Dr.  John  B.  Roberts  will 
read  a  paper  before  the  Pliila.  Co.  Medical  Society  on  "  Ether  Deaths," 
when  I  shall  be  bappy  to  see  you — if  you  feel  it  of  sufficient  im- 
portance to  be  present — a  personal  experience  in  four  cases  of  death 
from  anassthetics.  In  one  of  these  deaths,  (he  ether  employed  was 
your  preparation,  and  the  first  primary  death  in  Phila.  I  would  like 
you  to  inform  me  if  you  have  made  any  change  in  the  mode  of  manu- 
facture, or  are  you  less  careful  in  its  purification  ;  can  you  give  me 
any  hints  on  the  subject?     An  early  answer  will  oblige 

Yours  very  truly,  L.  Turnbull. 

Brooklyn,  N.  Y. 
Dr.  Laurence  Turnbuli.,  Phila. 

Ml/  Dear  Doctor, — Your  very  kind  invitation  is  at  hand,  but  I  am 
sorry  to  say  I  canuot  accept  it.  I  have  an  engagement  for  to-mor- 
row evening,  and  on  the  following  morning  have  to  be  in  Pough- 
keepsie  at  a  meeting  of  a  Hospital  Consulting  Board,  of  which  I  am 
a  member,  which  meeting  I  have  given  a  promise  to  attend.  I  have 
made  very  little  change,  in  either  the  process,  or  (he  character  or 
quality  of  the  ether,  made  by  me  in  the  past  25  years.  Of  course  the 
longer  one  does  a  thing  the  better  he  is  able  to  do  it,  and  the  ether 
of  to-day  is  a  little  better  and  cleaner  than  it  was  5  or  10  years  ago. 
But  that  a  certaiu,  though  very  small,  proportion  of  accidents,  fatal 
and  not  fatal,  would  occur  from  chemically  pure  ether,  I  have  not 
the  slightest  doubt.  Nor  have  1  a  doubt  that  they  would  occur  as  fre- 
quently with  chemically  pure  ether  as  with  that  which  I  sell,  and 
precisely  the  same  may  be  said  of  both  chloroform  and  nitrous  oxide, 
with  only  this  difference  :  that  the  conditions  in,  or  of,  antesthesia 
most  dangerous  to  life,  occur  least  frequently  with  nitrous  oxide,  and 
most  frequently  with  chloroform.  Where  most  is  to  be  gained,  is  in 
the  study  of  the  phenomena  of  the  accidents,  while  accepting  the 
conditions,  that  is  the  agents,  from  which  fewest  accidents  occur. 
Very  truly  yours,  E.  R.  Squibb. 

The  washed  ether  vi^hich  is  employed  as  an  anaesthetic  in 
the  vadous  hospitals  and  medical  institutions  of  the  United 
States,  is  manufactured  by  the  reliable  firm  of  Powers  & 
Weightman,  of  Philadelphia. 


MIXED   ANESTHETICS.  231 

With  profound  ansesthesia  from  ether,  the  vaso-motor  centres 
continue  to  act  for  a  much  longer  time,  than  when  chloroform 
is  employed.  Yet  the  ether  fortior,  and  even  the  washed,  will 
sometimes  suddenly  kill  certain  individuals  by  producing 
paralysis  of  the  vaso-motor  centres. 

The  following  experiment  was  made,  allowing  an  animal 
fully  to  recover  from  the  mixed  ansesthetic,  and  placing  it  under 
the  full  effects  of  Squibb's  ether  fortior,  (in  the  University  of 
Pennsylvania  laboratory,  April  27,  1885,  in  the  presence  of  Dr. 
John  D.  Thomas,  Prof.  Eeichert,  and  the  writer). 

Ether  was  crowded  on  it,  until  the  respiration  ceased,  and 
the  heart  almost  stopped  beating;  then  a  solution  of  100th  of 
a  grain  of  sulphate  of  atropia  was  introduced,  to  see  if  it 
had  any  power  to  stimulate  the  heart,  or  restore  respiration  in 
this  stage,  but  it  produced  no  such  results,  and  the  animal  was 
dead. 

If  the  same  amount  of  caution  is  employed  in  the  use  of  this 
more  powerful  agent,  as  in  the  use  of  chloroform,  the  number 
of  deaths  would  be  less.  It  must  always  be  borne  in  mind,  that 
in  full  anaesthesia,  no  matter  what  agent  is  employed,  there  is 
a  suspension  of  life  forces,  and  but  a  step  to  death. 

The  administration  of  atropine  may  be  resorted  to,  but  morphia 
subcutaneously  injected,  will  increase  the  risk  with  ether,  not  so 
much  with  chloroform.  There  are  many  individuals  who  have 
idiosyncrasies,  and  cannot  bear  even  what  is  known  as  a  small 
dose  of  morphia,  without  great  disturbance  of  the  stomach,  or 
faintness. 

It  has  been  suggested  to  add  atropine  to  the  morphia,  but  the 
experiment  just  related  will  demonstrate  that  it  will  not  relieve 
the  heart,  when  fully  under  the  influence  of  the  stronger  ether. 
There  are  no  agents  which  relieve  the  irritation  of  the  broncho- 
pulmonary mucous  membrane  so  well,  as  keeping  the  skin  warm 
and  free  from  moisture  or  draughts.  Above  all,  no  one  should 
give  the  ether  who  had  not  had  some  practical  experience  and 
is  not  desirous  of  witnessing  the  operation  ;  let  his  whole  atten- 
tion be  given  to  the  patient,  and  never  crowd  the  ether  after  the 
patient  has  become  fully  anaesthetized,  but  keep  it  off  at  a  dis- 
tance so  that  the  patient  may  get  a  small  portion  of  it.     Keep 


232       -  ARTIFICIAL   ANAESTHESIA. 

up  the  iufluence  of  the  ether  by  short  and  slight  inhalations 
well  diluted  with  warm  air. 

The  writer  still  holds  to  the  opinion  expressed  in  his  earlier 
edition,  that  the  safest  systemic  anaesthetic,  is  ether  in  pro- 
longed and  capital  operations,  and  in  this  opinion,  he  is  upheld 
by  the  majority  of  surgeons,  and  by  a  committee  of  the  British 
Medical  Association,  and  British  Medical  Journal,  also  in  the 
chief  medical  journals  of  the  United  States. 

In  the  face  of  the  constantly-recurring  notices  in  medical 
journals,  and  even  in  the  public  prints,  of  so  many  deaths  dur- 
ing the  administration  of  chloroform,  a  small  number  of  which 
are  published,  it  cannot  fail  to  be  patent  to  every  one,  that  there 
is  greater  danger  in  the  administration  of  chloroform.  It  will 
be  observed  that  it  does  not  affect  our  argument,  whether  such 
deaths  were  unavoidable,  or  were  the  result  of  faulty  adminis- 
tration, or  of  administration  of  an  insufficient  quantity,  as  we 
believe  to  be  not  unfrequeutly  the  case.  The  fact  remains 
that  deaths  do  occur;  and,  in  such  circumstances,  is  it  not 
the  duty  of  the  medical  profession,  to  endeavor  to  use  a  safer 
ansesthetic? 

Observations  made  on  rabbits  and  dogs,  showed  that  chloro- 
form had  a  most  disastrous  action  on  the  heart,  a^  well  as  upon 
the  respiratory  centre;  that,  while  ether  might  be  administered 
for  an  indefinite  period  without  affecting  the  heart,  no  sooner 
was  the  inhalation  of  chloroform  commenced,  than  the  right 
ventricle  began  to  distend,  and,  in  course  of  time,  the  cardiac 
contraction  ceased.  In  every  respect  but  one,  ether  is  superior 
to  chloroform.  It  has  been  stated,  that  it  has  one  disadvantage, 
viz.:  the  length  of  time  which  was  required  to  obtain  its  ac- 
tion. But  is  not  this  rather  an  advantage  as  regards  safety  ?  The 
difference  in  the  action  of  chloroform  and  ether  on  the  blood- 
pressure  is  shown  by  means  of  more  delicate  instruments 
than  those  obtained  by  the  Committee  of  the  Royal  Medical 
and  Ciiirurgical  Society,  the  report  of  which  was  published  in 
1874.  With  chloroform,  there  was,  at  first,  a  slight  transient 
rise  in  the  blood-pressure,  followed  by  a  gradual  but  irregular 
fall.  (See  Plate  22,  Fig.  3,  Sphygmographic  Tracings).  When 
ether  was  administered,  the  primary  rise  was  better  marked  and 


SPHYGMOGEAPHIC  TRACINGS.  'Zli6 

more  prolonged,  and  the  depression  which  followed  it,  very 
slight.  As  regards  chloroform,  the  pulse  fell  to  64,  60,  56, 
frequently,  and  in  one  instance,  to  48,  in  the  minute;  while  the 
rate  of  respiration  often  rose  much  above  normal,  and  on  one 
occasion  reached  to  a  rapidity  of  72,  per  minute.  The  same 
relation  between  these  two  anaesthetics  is  observed  in  regard 
to  respiration :  complete  arrest  of  the  pulmonary  circulation 
being  obtained  most  rapidly  by  chloroform,  and  with  the 
smallest  dose;  least  rapidly  by  ether. 

It  is  unfortunately  true  that  at  the  present  day,  ether  deaths 
occur  more  frequently  while  the  patient  is  under  th.e  surgeon's 
hands,  than  in  years  gone  by. 

Such  sudden  deaths  were  extremely  rare,  but  are  now  more 
frequent,  owing,  we  think,  to,  first,  the  use  of  a  purer  chem- 
ical ether;  and,  second,  to  the  larger  amount  employed,  as 
in  the  case  of  a  recent  death,  when  six  ounces  were  employed 
for  a  non-capital  operation,  which  could  have  been  performed 
under  a  local  ansesthetic.  These  six  ounces  are  just  the 
quantity  required  to  kill  a  healthy,  large-sized  dog  in  our 
hands. 

The  reason  for  employing  so  large  a  quantity  of  ether,  is  the 
strong  desire  to  etherize  the  patient  as  rapidly  as  possible,  and 
to  keep  him  profoundly  still,  so  as  to  perform  the  operation  as 
quickly  as  possible. 

The  number  of  deaths  from  chloroform  in  1887,  are  some  450, 
and  from  ether  in  the  same  year,  75 ;  and  it  is  well  known  that 
ether  is  much  more  extensively  employed  than  chloroform  in 
the  United  States  and  England,  while  in  Europe  chloroform  is 
the  agent  chiefly  used.  Life  in  Europe,  is  not  of  so  much  im- 
portance as  in  the  United  States  (?). 

In  ether,  it  is  almost  always  interruption  of  the  respiration, 
and  not  of  the  heart's  action,  and  there  is  a  chance  for  the 
use  of  artificial  respiration.  When  the  heart  is  the  first  to 
fail,  invert  the  body,  if  the  face  is  pale,  for  a  short  time,  until 
the  face  flushes,  so  as  to  restore  the  action  of  the  heart  and 
blood  current. 

SPHYGMOGEAPHIC  TRACINGS  (Plate  22).— The  following  is 
another  more  recent  series  of  sphygmographic  tracings.    There 


234 


ARTIFICIAL  ANESTHESIA. 


will  be  found  a  decided  difference  in  the  pulse  and  heart  in 
these  tracings :  Ether  in  Figs.  1  and  2,  Chloroform  in  Fig.  3, 
and  Bromide  of  Ethyl  in  Fig.  4. 

Plate  22— (Figs.  1-4). 


Figs.  1  and  2. — Ether,  first  and  second  stages. 


Fig.   3. — CnLOROFORM. 


Fig.  4.— Bromide  of  Ethyl,  or  Hydrobromic  Ether. 

It  will  be  noticed  how  much  freer  from  influence  upon  the 
heart  ether  is,  and  how  distinct  and  free  from  dangerous  dia- 
crotic  impressions  compared  with  chloroform,  which  depresses 
the  action  of  the  heart.  Hydrobromic  ether,  is  not  considered 
quite  so  dangerous  as  chloroform. 


w 


TREATMENT   OF   DANGEROUS   SYMPTOMS.         235 
t^^  Treatment  of    Dangerous   Symptoms. — (1).   Nelaton's       ^ 

plan   SUg^gestj    itnnniPfUntp    inv<^ramn     nf  f,}iPj    patipnt    in    nap  (\^  f^^ 

Tieart  failure,  and  artificial  respiration,  keeping'  if,  up  fnr  sr>mp    f^/:^;u^ 
fTme.^    (2).  inhalation  of  p^tt.  v.-x.  of  nitrite  of  amvl  may  be  ^  4      f /> 
given  early,  the  tongue  being  drawn  out  to  lift  the  epigflottia,  ^^J^  /5^ 
by  elevating  the  jaw  (Nancrede).     (3).  Stimulation,  in  case  ,  iryU^ 
respiration  is  affected,  but  not  entirely  suspended,  should  hft 
employed  by  means  of  eitker  atropine,  ammonia  to  the  nostril- 
cold  towel,  or  injection  of  ammonia  into  the  veins,  or  ice  in  the 
rectum.     (4).  Cjhiauiagfl,  if  employed,  may  be  administered  by  t^^''*-^'*^^ 
the  following  methods:  Horapath^-n\othod  {Laiiici,  1802)7  The 
positive  pole  is  placed  to  the^a^efmlTand  the  negative  pole,  over 
the  diaphragm.     A  rcflog-tiicLiuu  \h  tUuij  HAUtud  bet^vneu  the 
fiXth  pair  and  thc.pnoumogaotrio'.   This  is  used,  chiefly,  in  case  of 
respiratory  failure.   (5).  Tracheotomy,  and  inflation  of  the  lungs, 
by  a  catheter  passed  down  the  trachea,  as  suggested  by  Lan- 
genbeck  (Berlin,  1859),  may  be  resorted  to  in  desperate  cases,    .^s^;' 
In  a  discussion  upon  ansesthetics,  the  writer  stated  that  ether 


produces  inebriation  like  alcohol,  and\  the  patient  must  be  kept   'x^-^r^^g 
warm  while  under  its  infJaence.  or  the  temperature  will  sink      |   ,  ^j^ 


below  the  normal,  the  skin  become  cold  and  clammy,  with 
symptoms  ot  collapse.  The  pulse-rate  falls,  the  breathing  be-  ^ 
comes  embarrassed,  and  an  increase  of  secretion  tnlrr'i  pinrn  in 
the  lungs,  and  death  occurs  from  pulmonarv  oedema,  and  respi- 
ratory paralysis,  just  as  in  drunkards  who  are  exposed  to  cold. 
On  account  of  the  similarity  of  their  action,  alcoholic  stimu- 
lants should  not  be  given,  where  a  patient  appears  to  be  sinking 
after  ether  administration. 

Prof.  H.  C.  Wood,  endorsed  these  remarks,  about  alcohol  and 
ether,  and  said  that  the  more  closely  their  effects  on  the  lower 
animals  are  studied,  the  more  closely  are  they  seen  to  corre- 
spond. Atropia  and  digitalis,  on  the  other  hand,  are  of  value, 
but  their  effects  have  been  greatly  magnified ;  they  could  be 
given  in  much  larger  doses  than  we  are  accustomed  to,  and 
without  harm. 

In  considering  the  causes  of  death  after  ether,  we  must  not 
forget  that  patients  sometimes  die  of  heart-failure,  collapse,  or 
shock  after  operations,  where  no  ether  has  been  given.  Cases 
of  severe  burns,  or  of  surgical  operations,  frequently  rally  after 


Az^ 


236  ARTIFICIAL   ANAESTHESIA. 

the  operation,  but  die  afterward  with  secondary  syncope.  The 
danger  of  shock  is  very  much  reduced  where  the  antesthetic  is 
used,  and  in  cases  of  albuminuria  the  danger  from  shock  with- 
out the  ani:esthetic  might  be  greater  than  from  the  ether. 
Moreover,  the  amount  of  albumen  in  the  urine  is  not  an  index 
of  the  increased  risk,  for  in  some  cases  of  contracted  kidney 
the  proportion  is  very  small.  In  the  treatment  of  collapse  after 
ether.  Prof.  Wood  recommends  the  use  of  ammonia,  digitalis, 
and  proper  attention  to  the  position,  and  covering  of  the  patient. 

Prof.  Bartholow  said,  that  the  prevailing  impression  of  the 
profession,  of  the  comparative  safety  of  ether,  over  chloroform, 
makes  a  careful  investigation  into  fatal  cases  necessary,  in  order 
to  ascertain  all  the  causes  contributing  to  the  result,  so  as  to 
avoid  them  in  the  future. 

"  Where  there  is  danger  of  death  from  paralysis  of  respiration, 
there  are  two  means  of  stimulation  far  superior  to  medicine: 
they  are  artificial  respiration  and  faradism,  which  are  far  better 
in  these  cases  than  the  so-called  cardiac  stimulant,  atropia.  If 
the  cardiac  ganglia  are  beginning  to  fail  from  exhaustion,  the 
cardiac  stimulant  may  meet  with  no  response,  or  may  prove  in- 
jurious, for  its  first  effect  is  that  of  stimulation;  the  second,  ex- 
haustion. The  heart  may  be  sustained  by  intravenous  injection 
a^nd  artificial  heat.  He  most  decidedly  protested  against  the 
subcutaneous  injection  of  the  tincture  of  digitalis.  The  action 
of  digitalis  is  slow,  and  requires  several  hours  to  aifect  the 
heart.  In  a  case  reported  by  Boehm,  death  occurred  five  days 
after  the  administration  of  a  poisonous  dose  of  digitalis,  from 
paralysis  of  the  heart.  Digitalis  acts  by  stimulating  the  in- 
hibitory apparatus,  and  not  by  giving  increased  power  to  the 
cardiac  ganglia." 

Cases  in  which  Ether  should  not  be  employed  as  an 
Anaesthetic,  except  by  an  Expert  or  with  the  greatest 
CARE. — The  conditions  rendering  anaesthetics  dangerous  are: 
Fatty  degeneration  of  the  heart,  a  prominent  contra-indica- 
tion  where  there  is  pain  in  heart  region,  pale  face  and  arcus 
senilis  in  eye  ;  persons  who  have  an  alcoholic  history,  brain 
tumors  and  degenerations,  respiratory  obstructions  from  swollen 
epiglottis,  enlarged  tonsils,  oedema  glottidis,  laryngeal  paralysis, 
thoracic  tumors  or  aneurism,  emphysema  and  obstructed  pulse, 


DEATHS  FROM  ETHER.  237 

circulation  from  engorgement  of  right  lieart,  and  deficient  heart- 
power,  valvular  lesions,  provided  compensatory  hypertrophy  is 
not  proportionately  developed  ;  incomplete  anaesthesia,  during 
painful  surgical  procedures,  causing  death  from  shock,  as  the 
result  of  peripheral  irritation.  As  we  have  stated  before,  it 
is  of  the  greatest  importance,  that  attention  should  be  given  to 
the  condition  of  the  kidneys,  and  an  examination  made  of  the 
urine,  when  an  anaesthetic  is  to  be  administered.  Deaths,  un- 
accountable otherwise,  are  due  to  this  cause.  In  diseases  of 
the  kidneys,  the  blood  being  loaded  with  urea,  anaesthetics  al- 
most invariably  produce  convulsions,  coma  and  death. 

Prof.  Norris,  has  reported  two  cases  of  death  supervening  un- 
expectedly from  ether  after  operations  for  cataract.  Both 
recovered  consciousness,  but  died  comatose,  one  in  a  few  hours, 
the  other,  after  18  days ;  no  organic  lesion  was  found  at  post- 
mortem, except  Bright's  disease. 

Cases  have  also  been  reported  by  Emmet,  Hunt,  and  Mont- 
gomery, verified  by  post-mortem. 


CHAPTER    XV. 

Sudden  Deaths  under  Ether — Internal  Administration  of  Ether  — 
Ether  in  Mitigation  of  the  Agonies  of  Death — Ether  Intoxica- 
tion— Vivisection  with  Ether. 

In  the  first,  and  second  editions,  of  our  Manual,  the  opinion 
was  held  that  sudden  or  primary  deaths  from  ether  were  very 
rare  when  given  with  care  as  an  anaesthetic.  In  this,  we  were 
supported  by  the  Committee  of  the  Boston  Society  for  Med- 
ical Improvement,  a  high  professional  authority  at  that  time 
(1861).  Now,  at  times,  fatal  cases  occur,  irrespective  of  the 
disease  or  the  operation. 

No  one  has  done  more  to  prove  this  peculiar  action  of  ether, 
than  Dr.  J.  C.  Reeve,  of  Dayton,  Ohio ;  and  we  gladly  avail 
ourselves  of  the  experience  from  his  labors  in  this  direction,* 

*  It  is  stated  that  the  first  case  of  recorded  death  from  ether,  was  that  of  M.  Jo- 
hert,  of  the  St.  Louis  Hospital,  brought  before  the  Academy  of  Medicine  of  Paris, 
February,  1847  ;  and  the  second  reported  in  The  Medical  Gazette  by  Mr.  Roger  Nunn, 
at  the  Colchester  Hospital,  March  5,  1847. 


238  ARTIFICIAL  ANAESTHESIA. 

in  collecting  the  proof  by  cases.  From  the  reports  of  cases 
wliich  follow,  every  reader  ciui  judge  for  himself.  Only  such 
points  as  seem  to  be  essential  are  given,  for  the  sake  of  brevity, 
but  references  to  the  original  sources  have  been  carefully  made 
in  every  instance.  We  begin  with  the  first  reported  case  of 
death  from  ether: 

First  Case. — Paris,  July  10,  1847.  Patient,  male,  forty-five 
years  of  age;  operation  for  cancerous  affection  of  left  breast; 
"a  man  of  tolerably  robust  constitution,  which  the  disease 
had  not  yet  deteriorated,"  After  an  administration  of  about 
ten  minutes'  duration,  insensibility  was  manifest;  respira- 
tion was  loud,  slow,  but  exempt  from  rales,  and  the  surgeon 
began  the  operation.  "  The  incision  had  scarcely  commenced, 
and  only  a  small  quantity  of  dark  blood  had  escaped,  when 
the  countenance  changed,  and  the  respiration  became  slow. 
The  pulse,  examined  now  for  the  first  time,  was  soft,  full,  and 
very  slow ;  all  at  once  it  stopped ;  all  was  over."  The  post- 
mortem revealed  an  extremely  softened  spleen,  but  no  affection 
of  a  vital  organ.* 

Snowf  says:  "  This  patient  appears  to  have  died  rather  from 
the  want  of  admission  of  sufficient  air  to  the  lungs,  than  from 
the  effects  of  ether.  The  administration  had  been  slow,  and 
after  death  all  the  organs  gave  a  strong  odor  of  ether ;  but  to 
attribute  a  death  so  sudden  to  suffocation,  is  a  woeful  distortion 
of  evidence." 

Second  Case. — Female,  aged  fifty-five,  in  very  poor  health ; 
operation  for  tumor  of  superior  maxillary  bone,  at  Lyons,  Sep- 
tember 11,  1852.  The  operation  had  not  proceeded  far,  the 
ascending  ramus  had  not  yet  been  divided,  when  all  at  once 
respiration  ceased,  the  pulse  and  beating  of  the  heart  could 
not  be  felt,  and  all  efforts  at  resuscitation  proved  fruitless. 

Snow,  says  :  "  This  patient  evidently  died  of  hemorrhage ; " 
yet,  in  a  full  report  of  the  case  %  by  the  surgeon,  all  that  is 
said  of  this  is,  "  I  had  tied  some  vessels  upon  the  edges  of  the 
incision ! "     In  his  efforts  to  clear  ether  of  this  death.  Snow 

*  Trait^d'Anajsthesie  chirurgicale,  p.  250      Lallemand  et  Perrin,  Paris,  1863. 
t  On  Chloroform  and  Other  AnKsthetics,  p.  363.     London,  1868. 
X  TraiU  d'Ausesth^aie  cbir.,  p.  252. 


DEATHS  FEOM  ETHER.  239 

resorts  to  most  astounding  logic.  He  says :  "According  to  the 
results  of  my  experiments  on  animals,  ether  is  not  capable  of 
causing  the  kind  of  death  with  which  this  patient  died ! "  * 
therefore,  belladonna  could  produce  no  injurious  effects  upon 
man,  because  some  animals  can  eat  it  with  impunity  I 

The  next  four  cases  are  taken  from  Kappeler's  table,  which 
contains  reports  of  thirteen  cases  of  death  from  ether.  We  have 
not  access  to  the  original  reports,  even  of  the  cases  which 
occurred  in  this  country.  The  foot  references  are  those  given 
by  Kappeler. 

Third  Case. — Duming's  case,  Bellevue  Hospital,  New  York, 
1872.  Male,  sixty-eight  years  old,  etherized  for  adjustment  of 
fracture  of  thigh.  In  ten  minutes,  patient  was  fully  under  the 
influence.  After  some  manipulation,  inhalation  was  suspended 
for  four  or  five  minutes.  Inhalation  recommenced  on  account 
of  muscular  rigidity;  but  in  one  or  two  minutes  the  adminis- 
trator observed  the  pupils  suddenly  dilate,  and  respiration 
cease.  The  heart  was  still  beating.  All  attempts  at  resuscita- 
tion failed.     No  report  of  post-mortem  examination.! 

Fourth  Case. — Male,  aged  fifty-four,  resection  of  maxilla,  for 
caries.  An  incision  was  made  along  the  bone,  and  four  teeth 
extracted,  when  it  was  observed  that  the  patient  was  very  blue 
in  the  face.  Artificial  respiration  and  galvanism  were  without 
result.  Kappeler  says  :  "  The  editor  of  the  Boston  Journal, 
believes  that  the  patient  was  suffocated  by  blood  in  the  trachea." 
The  report  of  the  autopsy  makes  no  mention  of  this.J 

Fifth  Case. — Dr.  Sinclair's  case ;  Boston ;  operation  for  in- 
cision of  the  cervix.  Soon  after  the  operation  was  commenced, 
the  administrator  observed  that  the  pulse  was  gone,  and  respi- 
ration had  ceased.  All  efforts  at  resuscitation  proved  unavail- 
ing. The  post-mortem  examination  showed  Bright's  disease, 
chronic  pleuritis,  and  embolism  of  pulmonary  artery.  The  evil 
influence  of  the  former  as  to  the  effect  of  ether,  was  not  then 
recognized  as  now.§ 

*  Op.  cit.,  p.  364. 

+  Lancet,  1872. 

X  Brit.  Med.  Journal,  Dec,  1875  ;    Soston  Medical  and  Surgical  Journal,  Not.,  1875. 

g  Brit.  Med.  Journal,  October,  1876  ;  Boston  Medical  Journal. 


240  ARTIFICIAL  ANAESTHESIA. 

Sixth  Case. — Lowe's  case;  female,  aged  forty-eight,  of  healthy 
appearauce  and  of  toler.ibly  strong  build.  Operation  for  the 
removal  of  a  mammary  gland.  After  a  few  inhalations,  the 
patient's  face  suddenly  became  turgid,  and  the  hands  white.  The 
inhaler  was  at  once  removed,  the  tongue  brought  forward,  cold 
water  dashed  over  the  face,  and  the  chest  rubbed  with  brandy  ; 
but  the  breathing  became  stertorous,  the  face  became  more  and 
more  congested,  the  pulse  failed,  there  was  an  effort  at  vomit- 
ing, and  death  took  place  within  a  few  seconds.* 

Kappeler,  places  this  case  in  his  table,  without  any  question 
or  expression  of  doubt,  as  to  its  being  a  death  from  ether. 

/Seventh  Case. —  Male,  aged  sixty-nine,  much  exhausted; 
London  Hospital ;  strangulated  hernia.  There  was  much 
struggling;  as  the  lips  became  blue  the  inhaler  was  removed. 
Respiration  improved  for  a  brief  period,  but  remained  bad. 
The  pulse  became  worse  and  worse,  and  disappeared — while 
the  breathing  continued  for  thirty  seconds.  Heart  flabby,  the 
left  ventricle  not  contracted,  the  lungs  emphysematous,  and 
the  bronchi  filled  with  "  purulent  mucus."  Incarcerated 
hernia.f 

The  next  is  published  in  Holmes'  "Surgery."  In  afoot-note 
it  is  stated  that  the  case  was  never  before  published,  and  no 
names  are  given  in  connection  with  it.  We  will  now  say  that 
it  occurred  to  a  prominent  practitioner  of  Rhode  Island,  and 
the  report  was  furnished  us  by  our  friend.  Dr.  Charles  O'Leary, 
of  Providence. 

Eighth  Case.  —  Male,  aged  sixty-two,  addicted  to  drink. 
Ether  was  given  for  examination  of  hips  injured  the  day 
before,  patient  being  in  good  condition.  Two  ounces  of 
whiskey  given,  then  ether  administered  to  amount  of  three 
or  four  ounces.  Patient  never  fully  anaesthetized ;  pulse 
carefully  watched.  At  a  period  not  later  than  fifteen  to 
twenty  minutes  from  beginning  the  inhalation,  "  the  patient 
suddenly,  and  without  any  symptomatic  warning  whatever, 
stopped  breathing,  and  was  dead."  "  Death  was  instantaneous," 
another  observer  writes.     Post-mortem  examination  showed 

*  Bril.  Med.  Jour.,  Nov  17,  1877.     See,  also,  Hew  York  Med.  Record,  Jan.  5, 1878.     j 
t  BrU.  Med.  Jour.,  May  26,  1S77. 


DEATHS  FROM  ETHER.  241 

pleuritic  adhesions,  heart  full  of  dark  fluid  blood,  its  muscular 
structui'e  healthy;  the  valves,  especially  the  aortic,  affected 
with  atheromatous  deposit ;  liver  and  kidneys  congested,  the 
latter  studded  with  cysts. 

The  next  case  occurred  in  Philadelphia: 

Ninth  Case. — Male,  aged  sixty-seven ;  Pennsylvania  Hos- 
pital. A  feeble  old  man,  with  strangulated  hernia ;  a  hard 
drinker ;  had  suffered  much  from  exposure  and  want  of  food. 
After  anesthesia  by  ether  had  been  kept  up  some  time,  her- 
niotomy was  decided  upon.  Soon  after  the  operation  was 
commenced,  a  copious  bronchial  secretion  kept  filling  the 
patient's  mouth;  during  an  effort  to  expel  this  a  very  large 
portion  of  the  bowel  was  forced  out;  at  this  time  the  breath- 
ing became  labored,  the  pulse  faltered,  asphyxia  developed 
rapidly,  and  the  patient  expired  on  the  table.  This  was 
evidently  a  poor  subject  for  anaesthesia,  and  a  bad  subject  for 
operation,  yet,  in  the  language  of  the  reporter  of  the  case, 
"  the  ether  was  unquestionably  the  immediate  cause  of  death."* 

Tenth  Case. — Male,  aged  sixty-six,  for  some  weeks  had  ab- 
dominal symptoms,  which  finally  culminated  in  complete 
intestinal  obstruction,  and  right  lumbar  colotomy  was  under- 
taken.    "There  was  no  complicating  disease  in  heart  or  lungs, 

.  .  .  there  was  nothing  to  contraindicate  the  use  of  an 
anaesthetic,  or  to  make  one  more  than  usually  anxious  as  to 
its  effect."  Ether  given  by  Clover's  smaller  inhaler.  After 
five  minutes,  the  first  incision  was  made  by  Mr.  Pridgin  Teale. 
In  ten  minutes,  just  as  the  reporter  "was  engaged  in  counting 
the  carotid  pulse,  which  was  beating  evenly,  and  with  rather 
a  stronger  impulse  than  before  the  operation,  he  showed  an 
inclination  to  vomit,  and  ejected  a  quantity  of  brownish  fluid, 
smelling  strongly  of  brandy.  He  then  took  one  deep  inspira- 
tion, and  seemed  as  if  inclined  to  vomit  again :  but  his  head 
sank  back  on  the  pillow,  and  he  quietly  died,  making  no 
further  respiratory  effort,  except  one  short  gasp  during  artifi- 
cial respiration.  No  post-mortem  was  allowed,  but  examina- 
tion failed  to  show  any  mechanical  obstruction  to  breathing. 

*  Paper  by  Dr.  Thomas  G.  Morton,  Amer.  Journ.  of  Mei.  ScL,  Oct.  1876,  p.  415. 
11 


242  ARTIFICIAL  ANiESTHESIA. 

The  inhaler  showed  that  a  little  more  than  an  ounce  of  the 
ether  had  heen  used."  * 

The  following  two  cases  are  from  a  paper  on  "Deaths  from 
Anesthetics  in  1885,"  by  Ernest  H.  Jacobs,  M.A.,  M.D.f 

Eleventh  Case. — Male,  aged  sixty-two  years,  at  London  Hos- 
pital. Ether  given  to  reduce  a  dislocation  of  shoulder.  "  In 
three  minutes  he  began  to  look  pale,  his  breathing  was  feeble; 
a  dusky  pallor  increased  in  spite  of  artificial  respiration.  At 
the  post-mortem  the  lungs  were  found  emphysematous  and 
congested,  and  there  was  bronchitis  (?).  The  heart  was  flaccid 
and  fatty,  with  adherent  pericardium." 

Twelfth  Case. — Girl,  aged  ten  years,  much  emaciated  and 
looking  very  ill ;  to  be  sounded  for  a  calculus.  When  she  had 
taken  but  a  iew  inhalations,  she  was  observed  to  be  very  pale, 
"  the  pulse  ceased,  the  breathing  continued."  AH  efforts  of 
resuscitation  were  in  vain.  "  This,"  the  reporter  says,  "  is  the 
most  remarkable  case  of  the  kind  I  have  ever  known.  The 
patient  took  not  more  than  a  drachm  of  ether,  and  died  in  a 
precisely  similar  manner  to  that  which  generally  obtains  in 
the  case  of  chloroform." 

ThiH'  enth  Case. — Male,  aged  fifty  years,  suffering  from  severe 
inflammation  of  the  bowels,  due  to  obstruction.  Ether  was 
carefully  administered  preparatory  to  an  operation.  He  in- 
haled it  without  the  slightest  hesitation  or  discomfort,  but 
had  not  taken  more  than  three  or  four  inhalations  when  he 
fell  back,  breathed  once  or  twice,  and  died.  At  the  post- 
mortem examination,  there  was  found  considerable  purulent 
effusion  in  the  peritoneal  cavity ;  at  the  lower  part  of  the 
descending  colon  was  a  malignant  mass  of  the  size  of  a  small 
cocoa-nut,  blocking  the  canal.  In  the  right  ventricle  of  the 
heart  was  a  fibrinous  clot  attached  to  the  tricuspid  valve. 
The  medical  men  did  not  think  the  patient  died  from  the 
ether,  because  death  occurred  so  very  early  in  the  administra- 
tion. The  post-mortem  failed  to  explain  so  sudden  a  death, 
without  the  ether  as  a  factor. 

"This  collection  of  cases,  is  not  presented  as  complete ;  I  am 

*  London  Lancet,  Sept.  4,  1880,  p.  370. 

t  Bril.  Med.  Journal,  March  13, 1886,  p.  489. 


DEATH  FROM  ADMINISTRATION  OF  ETHER.       243 

very  certain  that  it  is  not  so.  To  make  it  so,  I  have  not  gone 
beyond  the  resources  of  my  own  library.  I  have  not  given 
any  cases  in  which  death,  evidently  due  to  ether,  took  place  at 
a  period,  more  or  less  remote  from  the  administration.  There 
are  many  such  on  record.  Nor  will  I  extend  this  paper,  by 
presenting  cases  in  which  dangerous  symptoms  occurred  under 
ether;  just  such  symptoms  as  patients  had  from  the  A.-C.-E. 
mixture.  I  have  kept  closely  to  my  text :  '  Ether  in  the 
human  subject  may  cause  death  as  suddenly,  as  unexpectedly,  and 
in  the  identical  manner  that  chloroform  does.'  Whether  the 
evidence  adduced  sustains  the  proposition  or  not,  must  be  left 
to  others  to  determine.  If,  however,  the  ground  be  taken  that 
the  cases  adduced  did  not  die  from  ether,  then  it  is  incumbent 
upon  the  objector  to  show  what  they  did  die  from. 

"  Finally,  I  wish  to  disclaim,  in  the  most  emphatic  manner, 
any  feeling  of  partisanship  in  this  matter.  I  have  no  '  case ' 
to  make  out  against  ether.  I  have  no  anaesthetic  to  advocate 
as  perfectly  safe,  for  such  a  thing  does  not  exist.  I  am  ready 
to  admit  that  probably  ether  is  the  safest  ancesthetie  we  possess  for 
surgical  purposes.  I  am  ready  to  assent  to  the  proposition  that, 
theoretically,  any  mixture  of  ansesthetica  increases  in  danger, 
in  proportion  as  chloroform  is  added  to  it." 

This  finishes  Dr.  Reeves'  collection  of  cases  and  his  opinion 
of  ether  in  comparison  with  chloroform.     (The  Italics  are  ours.) 

A  Deatk  Dueing  the  Administration  of  Ether.* — 
"On  the  3d  of  August,  1887,  I  was  called  to  visit,  by  ap- 
pointment, Mr.  R.  D.,  set.  forty-five,  at  his  hotel  in  Philadel- 
phia, for  the  purpose  of  removing  two  ulcerating  hemorrhoids, 
which  had  resisted  the  ordinary  means  of  treatment  for  several 
months,  and  were  causing  the  patient  great  discomfort.  Dr. 
White  was  asked  to  accompany  me  and  administer  the  ether. 
There  were  no  ascertainable  reasons  why  an  anaesthetic  should 
not  be  given,  as  neither  the  heart  nor  kidneys  were  diseased, 
and  the  patient  appeared  to  be  in  good  health.  Only  one  year 
previous  I  had  divided  and  stretched  the  sphincter  ani  of  Mr.  D. 
for  fissure,  administering  the  ether  myself,  and  after  antesthesia, 

*  By  D.  Hayes  Agnew,  M.D.,  TSIedical  News,  Nov.  19,  1887. 


244  ARTIFICIAL  ANESTHESIA. 

entrusting  the  agent  to  a  friend  of  the  patient,  who  was  pres- 
ent, for  the  brief  time  required  for  the  operation.  About  six 
ounces  were  taken  at  this  time. 

"  At  the  time  of  the  last  operation  nothing  occurred  durinsf 
the  early  stage  of  the  inhalation,  other  than  what  is  witnessed 
every  day  when  ether  is  exhibited.  In  the  course  of  fifteen 
minutes  the  patient,  though  somewhat  rigid,  was  placed  across 
the  bed.  One  of  the  tumors  was  dragged  down,  transfixed, 
and  ligated  with  a  double  ligature.  When  about  to  .seize  the 
second,  the  breathing,  which  had  been  strong  and  free,  sud- 
denly ceased.  The  operation  was  immediately  suspended,  and 
the  usual  methods  for  resuscitation  instituted.  These  con- 
sisted in  examining  the  throat  for  the  probable  presence  of 
some  obstructing  cause,  dragging  the  tongue  forward,  the  use 
of  artificial  respiration,  flagellating  the  surface  with  the  end 
of  a  wet  towel,  ammonia  to  the  nose,  partial  inversion  of  the 
patient,  and,  finally,  the  passage  of  the  electro-galvanic  cur- 
rent through  the  phrenic  nerves.  Notwithstaading  these 
measures  were  persisted  in  for  at  least  three-quarters  of  an 
hour,  during  twenty-five  minutes  of  which  time  the  pulsations 
of  the  heart  could  be  recognized,  not  a  single  effort  of  natural 
respiration  occurred.     The  man  was  dead. 

"The  post-moriem,  made  by  Dr.  Formad,  revealed  complete 
collapse  of  the  lungs,  marked  traces  of  an  old  meningitis, 
attributed  to  a  former  sunstroke,  and  what  satisfactorily  ex- 
plained the  sudden  termination  of  life,  the  rupture  of  a  calci- 
fied vessel  in  the  floor  of  the  fourth  ventricle,  the  recognized 
physiological  centre  of  respiration ;  all  the  vessels  comprising 
the  circle  of  Willis,  were  in  a  similar  state  of  atheromatous 
degeneration.  It  was  evident,  therefore,  that  the  increased 
vascular  tension  of  these  cerebral  vessels,  caused  by  the  ether, 
determined  the  lesion,  a  result  which  might  have  followed  any 
unusual  excitement,  mental  or  physical.  The  heart  and  kid- 
neys were  healthy. 

"The  question  naturally  occurs.  Could  this  sad  disaster 
have  been  prevented  ?  Certainly,  in  view  of  all  the  circum- 
stances, it  could  not.  First.  The  ether  was  that  known  as 
Squibb's.     The  can   contained    eight  ounces;  two  ounces  re- 


DE.    AGNEW'S   CASE.  245 

mained  in  the  vessel ;  two  ounces,  it  is  fair  to  suppose,  had 
been  retained  in  the  folds  of  the  towel,  leaving  four  ounces, 
or,  at  most,  less  than  five  ounces  which  had  been  inhaled. 
Second.  There  was  a  sufficient  admixture  of  atmospheric  air 
with  the  respired  vapor,  as  the  anaesthetic  was  administered 
from  an  ordinary  towel,  folded  into  a  cone,  and  with  an  open- 
ing at  the  apex.  Third.  The  position  of  the  administrator, 
Dr.  White,  that  of  reclining  alongside  of  the  patient,  with  the 
face  of  the  latter  in  full  view,  would  have  enabled  him  to  de- 
tect at  once,  any  signs  of  approaching  danger,  which,  from  his 
long  experience  in  giving  anaesthetics,  would  have  been 
quickly  recognized ;  and,  last,  the  impossibility  of  being  able 
to  ascertain  during  life,  the  state  of  the  blood-vessels  of  the 
brain,  disclosed  by  the  autopsy,  and  rendered  very  improbable 
in  a  man  of  forty-five  years  of  age. 

"  After  forty  years  of  surgical  work,  often,  too,  of  the  gravest 
character,  and  sometimes  requiring  prolonged  anaesthesia, 
without  an  accident  in  a  single  instance,  I  had  come  to  believe 
that  the  exhibition  of  ether,  unless  recklessly  administered, 
was  entirely  free  from  danger.  Several  deaths,  I  am  aware, 
have  been  reported,  from  time  to  time,  from  its  use,  even  in 
the  hands  of  the  most  careful  operators,  but  I  never  could 
divest  my  mind  of  the  idea,  that  in  these  cases  there  was  some 
undetected  element  involved,  more  influential  in  the  issue  than 
the  ether,  as  in  the  present  instance. 

"The  following  case,  which  came  directly  under  my  own 
observation  only  a  few  weeks  before  the  death  of  Mr.  D.,  is  in 
point : 

"I  was  called  to  one  of  our  suburban  towns  to  see  a  case  of 
strangulated  hernia.  The  patient  was  a  female  about  seventy 
years  of  age.  The  intestine  had  been  incarcerated  for  three 
days.  Her  pulse  was  quite  good,  and  there  were  no  signs  of 
collapse.  I  noticed  the  pupils  were  much  contracted,  no 
doubt  from  the  opium  which  had  been  administered.  I  di- 
rected her  medical  attendant  to  place  the  patient  properly  in 
bed,  and  prepare  a  cone  for  giving  the  anaesthetic,  while  I 
made  my  preparation  for  the  operation.  This  was  done.  In  a 
few  minutes  I  was  ready  to  proceed,  and  then  told  the  doctor 


246  ARTIFICIAL   AN.TSSTHESIA. 

to  give  the  etber.  While  reaching  for  the  bottle,  and  before 
removing  the  cork,  the  patient  gave  a  sudden  convulsive 
movement,  at  the  same  time  ejecting  a  large  amount  of  ster- 
coraceous  matter  from  the  stomach,  and  expired  in  a  moment. 
Had  the  etherization  been  commenced,  or  the  operation  begun, 
before  the  death  of  the  woman,  the  fatal  result  would  have 
been  charged  to  either  the  anaesthetic  or  to  the  knife." 

Deaths  from  Ether  and  Chloroforiu. 

There  are  many  ftital  accidents  from  both  ether  and  chloro- 
form which  are  never  reported.  Dr.  Wickham,  of  Chicago,  a 
friend  of  the  writer,  reported  a  death  from  ether  in  the  prac- 
tice of  a  friend  of  his,  and  Dr.  F.  H.  Akin,  in  the  discussion 
of  Dr.  McGuire's  paper,  stated  as  follows :  "  I  know  of  one 
death  from  ether  occurring  in  Baltimore  several  years  ago, 
where  an  operation  was  being  performed  for  a  uterine  fibroid, 
in  a  patient  very  greatly  reduced  by  hemorrhage.  This,  I  be- 
lieve, was  never  published.  Again  some  years  ago,  a  friend 
in  one  of  our  towns  in  West  Virginia  told  me  of  a  fatal  case 
from  chloroform  happening  to  him.  I  asked  him  if  he  had 
published  an  account  of  it.  '  No,  indeed ;  I  felt  too  badly,  and 
besides,  it  was  published  enough,  without  my  reporting  it,' 
was  the  substance  of  his  reply.  I  have  been  told  of  others 
occurring  in  military  practice  during  the  late  Civil  War, 
which  have  never  been  reported." 

Reduction  of  Temperature  by  the  Action  of  Ether, 
as  a  Cause  of  Death. 

The  bodily  temperature  is  reduced  by  the  action  of  ether. 
Among  twenty  cases  the  average  diminution  of  temperature 
was  0.68°  C.  The  minimum  fall  was  0.3°  C. ;  the  maximum 
was  1.5°  C.  Among  twelve  cases,  uncomplicated  by  any  febrile 
movement,  the  average  fall  was  0.52°  C.  In  thirteen  of  the 
nineteen  cases  in  which  the  commencement  of  heat-depression 
was  noted,  the  mercury  began  to  descend  when  inhalation  had 
been  continued  for  ten  minutes.  In  five  instances,  fifteen 
minutes,  and  in  one  instance,  twenty  minutes  elapsed,  before 
any  depression  was  noticed. 


EEDUCTION   OF   TEMPERATURE.  247 

The  shortest  time  in  which  the  greatest  fall  was  reached,  was 
twenty  minutes  after  the  commencement  of  inhalation ;  the 
longest  time  was  two  hours.  It  was  always  remarked  that  the 
greatest  depression  of  temperature  accompanied  the  most 
abundant  use  of  the  anaesthetic  agent,  and  the  most  profound 
anaesthesia. 

The  only  cases  in  which  elevation  of  temperature  is  observed 
are  presented  by  patients  in  whom,  for  a  brief  period  during 
the  stage  of  excitement,  an  increased  muscular  activity  liber- 
ates a  slight  increase  of  heat.  This  reduction  of  temperature, 
is  a  secondary  cause  of  death  from  ether,  but  not  a  primary 
one.  We  have  never  found  the  skin  or  pulse  to  fail  under 
ether  until  the  inhalation  had  stopped;  then  the  skin  became 
moist,  clammy  and  cold;  and,  if  exposed,  collapse  of  the  lungs. 
If  the  system  is  not  able  to  remove  the  moisture  from  the  skin, 
the  lungs  must  suffer,  and  the  patient  dies. 

In  many  persons  the  lungs  contain  so  little  residual  air  that 
the  ether  vapor  fills  them  almost  entirely,  not  only  depriving 
the  blood  of  its  required  oxygen,  but  also  producing  its  special 
influence  upon  the  brain  and  nerves  of  sensation  and  motion. 
It  is  true  that  no  apparatus  now  at  our  disposal  entirely  pre- 
vents air  from  reaching  the  lungs;  but  the  great  difficulty  lies 
generally  in  the  sponge  or  towel  used  becoming  so  wet  with 
the  watery  vapor,  that  a  perfectly  air-tight  covering  for  the 
mouth  and  nose  is  formed,  necessarily  producing  asphyxia  if 
left  too  long.  Ether,  like  water,  may  also  fill  the  trachea, 
preventing  the  air  from  reaching  the  lungs,  as  often  noticed 
in  drowned  persons,  the  trachea  being  found  full  of  water — 
undoubtedly  a  cause  of  death  ;  but  as  a  general  rule,  the  real 
cause  of  death  from  chemically  pure  ether,  is  direct  paralysis  of 
respiration,  followed  by  secondary  paralysis  of  the  heart.  A 
death  having  occurred,  to  all  appearances,  from  ether  in  Phil- 
adelphia was  so  reported,  but  has  since  been  questioned  by  the 
editor  of  the  Medical  News,  June  4, 1887,  and  we  give  it  as  it  was 
published,  as  it  contains  much  that  is  useful  and  to  the  point: 

"  Was  it  a  Death  due  to  Ether? — We  reply  in  the  nega- 
tive. The  case  in  question  occurred  in  Philadelphia  last  week, 
and  was  the  subject  of  comment  in  the  newspapers,  and  of  an 


248  ARTIFICIAL  ANiESTHESIA. 

extra-judicial  opinion  by  the  coroner.  The  facts  with  which 
we  are  concerned  are  theae  : 

"A  minor  surgical  operation  being  necessary,  ether  was  em- 
ployed as  an  anjesthetic.  No  accident  happened  during  the 
anaesthesia,  and  no  unusual  incidents  followed  the  operation 
until  the  fifth  hour  thereafter,  when  the  patient  suddenly  ex- 
pired. A  jury  summoned  by  the  coroner,  rendered  a  verdict 
which  ascribed  the  death  to  ether,  but  implied  no  censure  of 
the  two  physicians  in  charge  of  the  case.  The  coroner,  how- 
ever, animadverted  with  no  little  severity  on  that  lack  of  skill 
which  failed  to  detect  the  'fatty  heart.'  The  coroner's  physi- 
cian, who  conducted  the  autopsy,  testified  to  the  existence  ot 
fatty  degeneration  of  the  cardiac  muscular  tissue,  and  without 
hesitation  referred  the  fatal  ending  of  the  case  to  the  action  of 
ether.  An  examination  of  the  brain  appears  not  to  have  been 
made,  nor  was  the  vascular  system  inspected  with  the  view  to 
detect  thrombus  or  emboli.  Such  omissions,  if  made,  must 
cast  doubt  over  the  conclusions  arrived  at  from  insutficient 
data,  and  are  the  more  reprehensible,  since  the  physicians  are 
held  up  to  public  reprobation  when  innocent  of  offence. 

"To  ordinary  observation,  without  prejudice,  the  two  facts 
of  the  case — the  inhalation  of  ether,  the  death  several  hours 
after — seem  too  remote  to  have  the  relation  of  cause  and  effect. 
The  supposed  fatty  heart  bore  the  strain  of  the  ether  inhala- 
tion, and  the  surgical  procedure,  and  yet  succumbed  when  the 
anaesthetic  was  no  longer  in  action,  and  the  shock  of  the 
operation,  if  any,  had  passed  away.  It  is  no  doubt  true,  as 
recently  stated  in  these  columns,  that  a  fatal  result  may  occur 
from  ether  inhalations  several  days  after,  becauvse  of  pulmo- 
nary inflammation  induced  by  prolonged  contact  of  ether  vapor. 
It  is  not  alleged  that  the  case  in  question  was  of  this  charac- 
ter; but,  finding  a  fatty  heart,  the  fatal  ending  required  no 
further  explanation.  Did  this  conclusion  turn  on  the  naked- 
eye  appearances,  or  was  it  decided  by  a  microscopic  examina- 
tioji  of  ihe  muscular  elements? 

"  The  coroner  seemed  to  have  been  outraged  in  his  inner- 
most moral  consciousness,  that  the  fatty  degeneration  of  the 
heart  had  eluded  ante-mortem  examination.     We  opine  that 


WAS    IT   A    DEATH    FROM    ETHER?  249 

his  strictures  are  not  justified  by  our  existing  knowledge  of 
the  rational  and  physical  signs  of  this  morbid  condition.  We 
have  the  conviction  that  considerable  fatty  degeneration  may 
exist  without  any  definite  symptoms,  and  all  of  the  usual 
signs  of  this  affection  may  co-exist  with  a  normal  state  of  the 
organ.  Assuming  that  the  heart  of  this  patient  had  under- 
gone, to  some  extent,  degenerative  changes,  should  this  con- 
dition inevitably  preclude  the  administration  of  ether?  An 
answer  to  this  question  is  furnished  us  by  the  mode  of  dying 
in  ether  narcosis.  It  is  now  conceded  on  all  sides,  that  failure 
of  the  respiration  is  the  mode,  the  action  of  the  heart  being 
rather  stimulated,  than  depressed  by  ether. 

"To  connect  the  death  of  this  patient  with  the  ether  inhala- 
tion after  several  hours  had  elapsed,  is  to  do  violence  to  every 
fact;  to  assume  as  a  cause  of  the  fatal  ending,  a  condition  of 
the  heart  which  had  passed  through  the  ordeal  of  a  surgical 
operation  and  complete  insensibility,  is  to  tax  credulity  above 
its  power  of  endurance ;  and  to  ignore  the  results  of  physio- 
logical investigations  that  have  demonstrated  the  nature  and 
character  of  the  dangers  in  anaesthesia  by  ether,  is  to  sub- 
stitute for  exact  knowledge  the  vagaries  of  uninstructed  opin- 
ions. 

"  To  permit  the  coroner  to  give  utterance  to  extra-judicial 
opinions,  that  reflect  on  the  judgment  and  attainments  of  phy- 
sicians who  have  the  misfortune  to  come  within  his  jurisdic- 
tion, is  to  touch  nearly  the  honor  of  the  medical  profession. 
To  permit  the  coroner's  physician  to  announce  hasty  opinions 
after  insufficient  examination  that  discredit  the  knowledge 
and  reflect  on  the  integrity  of  the  physicians  concerned,  is  to 
place  in  his  hands  an  opportunity  for  mischief  that  can  hardly 
fail  of  being  utilized.  If  post-mortem  investigations  that  in- 
volve mortification  or  disgrace,  or  merely  annoyance,  are 
conducted  without  giving  an  opportunity  to  the  physician  im- 
plicated to  observe  for  himself,  is  it  not  certain  that  a  grievous 
wrong  is  being  perpetrated,  and  the  good  name  created  by  a 
life  of  honest  endeavor,  put  at  the  mercy  of  caprice,  of  preju- 
dice, or  of  ignorance?  We  learn  that  in  the  case  now  under 
consideration,  the  post  mortem  was  conducted  without  acquaint- 

11* 


250  ARTIFICIAL  ANAESTHESIA. 

iug  the  physicians  concerned,  and  thus  affording  them  the 
opportunity  to  prepare  for  their  own  defence. 

"  It  must  be  obvious  to  the  least  observant  physician,  that 
there  is  an  increasing  distrust  of  the  medical  profession,  grow- 
ing out  of  those  personal  discussions  in  which  the  integrity 
and  acquirements  of  each  other  are  culled  in  question.  The 
world  is  apt  to  adopt  that  view  of  a  body  of  men  to  which  they 
themselves  give  expression.  In  these  times  of  combinations, 
of  syndicates,  of  organizations,  the  medical  profession  is  ap- 
parently engaged  in  a  process  of  disintegration  rather  than 
solidarity." 

A  Patient  Succumbs  to  the  Ether  on  the  Operating 
Table  at  Blockley.* — Donate  Ferro,  an  Italian  journeyman 
tailor,  died  on  the  operating  table  in  the  Clinic  Hall  of  Block- 
ley  Hospital  on  Saturday,  June  8,  1889,  about  noon,  while 
undergoing  a  surgical  operation  for  hip-joint  disease.  The 
immediate  cause  of  death  was  the  quantity  of  ether  adminis- 
tered to  the  patient. 

Ferro  was  36  years  old,  and  lived  at  827  Fitzwater  Street, 
until  about  three  months  ago,  when  he  became  an  inmate  of 
the  Philadelphia  Hospital,  suffering  from  a  disease  of  the 
hip-joint  which,  when  the  hospital  physicians  began  to  treat  it, 
had  reached  what  is  called  the  third  stage.  There  was  lit- 
tle superficial  evidence  of  pus  formation  at'  the  time  Ferro 
came  to  the  hospital.  Shortly  after  this,  the  joint  became 
greatly  swollen.  The  doctors  found  that  there  was  an  internal 
and  external  abscess  of  the  pelvis.  An  incision  was  made  in 
the  outer  sac  through  which  the  pus  flowed,  thus  proving  that 
what  Ferro  was  suffering  from  was  a  disease  of  the  socket  of 
the  joint.  Ferro  began  to  suffer  intensely  then,  and  about 
May  1,  he  could  not  sleep  except  when  under  the  influence  of 
narcotics. 

Two  weeks  ago,  the  doctors  made  an  examination  of  the 
limb.  Ferro  was  antesthetized  at  the  time  for  the  purpose  of 
destroying  some  adhesions.  The  physicians  noticed  that  there 
were  no  ill  effects  from  the  ether  at  the  operation.    About 

»  Phila.  Med.  Times,  No.  404,  May  19. 


FEEEO'S   DEATH.  251 

Thursday  of  last  week  a  consultation  was  held  upon  the  ad- 
visability of  aspirating  the  joint,  but  it  was  postponed  until 
Saturday.  On  that  day  Dr.  A.  W.  Ransley,  of  1230  South 
Tenth  Street,  who  is  one  of  the  attending  physicians  of  the 
Philadelphia  Hospital,  decided  to  make  the  operation ;  he 
was  assisted  in  it  by  resident  physicians  Samuel  M.  HamilJ, 
and  Charles  Walter. 

Ferro  was  taken  from  the  ward  about  10  o'clock  on  Saturday 
morning,  and  prepared  for  the  clinic,  in  which  about  100  stu- 
dents from  different  medical  colleges  were  assembled.  The 
physicians  had  agreed  previously  that  an  operation  was  neces- 
sary to  save  Ferro's  life,  as  he  could  not  live  under  the  cir- 
cumstances more  than  a  month.  Ferro  was  confident  of  his 
approaching  end,  it  is  said,  and  urged  the  doctors  to  proceed 
with  the  operation.  He  was  accordingly  examined,  and  it  was 
thought  that  he  was  physically  able  to  stand  the  treatment. 
When  Ferro  was  brought  into  the  clinic  he  was  under  the 
influence  of  the  drug,  and  while  the  operation  was  in  progress 
for  over  three-quarters  of  an  hour,  it  is  said  that  a  towel  was 
held  over  the  mouth  of  the  patient,  and  ether  freely  applied. 

About  11.45  o'clock,  one  of  the  doctors  noticed  that  Ferro's 
face  was  blanched,  his  pulse  feeble  and  respiration  very  slow. 
Heroic  measures  were  at  once  resorted  to  to  restore  the  pa- 
tient. Aromatic  spirits  of  ammonia,  whiskey  and  ether,  were 
injected  hypodermically,  and  everything  known  to  science 
tried.  In  less  than  ten  minutes  after  Ferro's  condition  was 
first  noticed,  he  was  dead.  To  allay  any  excitement  that  might 
occur  among  the  students  who  witnessed  the  operation,  and  the 
sudden  efforts  to  restore  the  subject,  the  body  was  wheeled 
from  the  hall,  and  only  a  few  of  them  learned  of  the  death. 

The  body  was  at  once  removed  to  the  Morgue  and  Dr.  Eans- 
ley  in  person,  called  upon  Coroner  Ashbridge,  and  notified  him 
of  the  death.  The  latter  ordered  a  post-mortem,  which  was  held 
the  next  day  in  the  Morgue,  at  2  o'clock.  When  the  coro- 
ner's physician  made  the  incision  in  the  abdomen  there  was  at 
once  a  perceptible  odor  of  ether  throughout  the  room  and 
every  organ  as  it  was  opened  emitted  the  odor  of  the  drug.  It 
was  a  remarkable  incident  in  the  examination,  and  it  seemed 


252  ARTIFICIAL   ANJiJSTHESIA. 

that  Ferro's  body  was  thoroughly  impregnated.  There  is  no 
doubt  that  the  operation  was  a  justifiable  one.  Life  could  not 
be  prolonged  for  more  than  a  month.  There  were  symptoms  of 
blood  poisoning  from  the  scrofulous  abscess  at  the  hip  joint, 
which  extended  to  the  abdominal  cavity,  where  there  was  also 
a.]}soas  abscess. 

Coroner  Ashbridge  began  an  inquest  in  the  case,  and  after 
Ferro's  brother  testified  to  identifying  the  body  the  inquest 
adjourned.  It  is  a  certainty  that  death  ensued  from  the  effects 
of  the  ether. 

Death  while  under  the  Influence  of  Ether. — On 
Monday,  January  30,  1888,  a  man — Richard  McKee — aged 
fifty-three,  of  No.  2016  Woodstock  Street,  Philadelphia, 
received  an  injury  to  his  nose  from  a  fall.  Drs.  A.  and  B. 
administered  ether,  which  was  soon  followed  by  a  comatose 
state.  After  effurts  without  result,  and  while  in  this  condition, 
he  was  taken  to  the  Philadelphia  Hospital,  over  the  river — a 
distance  of  a  mile — in  very  cold  weather,  where  everything 
was  done  to  overcome  this  condition  without  success.  It  was 
found,  on  examination  of  the  urine,  that  he  had  Bright's  dis- 
ease of  the  kidneys,  finding  albumen  and  casts  in  his  urine, 
and  that  he  was  suffering  from  ursemic  convulsions.  The  re- 
moval of  the  patient  during  such  cold  weather  was,  in  itself,  a 
very  injudicious  procedure,  and  has  been,  in  almost  every  in- 
stance, the  cause  of  death  from  congestion  of  the  lungs,  etc. 
There  is  always  an  active  reduction  of  temperature  in  the 
body  on  the  use  of  ether.  No  post-mortem  was  allowed  by  the 
family  of  the  man.  The  following  are  the  observations  of  Dr. 
Osier  on  the  case,  with  another  such  case  from  a  friend.  We 
called  the  attention  of  the  profession  as  early  as  March  9th,  in 
American  Medical  Association,  referring  to  Emmet's  experi- 
ments, and  also  to  Norris'  case.  (See  pamphlet  and  cases  of 
our  own  knowledge  of  the  danger  in  such  cases.) 

Fatal  Coma  after  Ether  Anesthesia. — A  deepening 
and  fatal  coma  after  ether  may  be  due  to  apoplexy  or  to 
uraemia.*  An  illustration  of  the  former  occurred  in  Mon- 
treal  eight  or  ten  years  ago  in  the   practice   of  Dr.   Fuller, 

*  Editorial  Canada  DIedical  and  Surgical  Journal,  March,  1888,  p.  309. 


DEATH   FEOM   ETHER.  253 

in  an  operation  for  cataract  in  an  old  man.  Cerebral 
hemorrhage  was  present  (post-mortem).  On  the  26th  of  Jan- 
uary, 1888,  a  man  aged  fifty-three  was  admitted  to  Dr.  Wm. 
Osier's  ward  in  the  Philadelphia  Hospital,  to  whom,  on  the 
25th,  ether  had  been  given  by  Dr.  Earackson,  to  stitch  a 
wound  on  the  face  due  to  a  fall.  The  patient,  a  sober  man, 
had  not  been  well  for  some  time,  and  was  very  tottery  on  the 
25th,  when  he  fell  and  cut  his  nose.  According  to  the  friends, 
he  took  the  ether  very  well,  and  the  operation  did  not  last 
long;  but  he  never  regained  consciousness.  When  seen  on 
the  morning  of  the  27th,  the  temperature  was  97.5°,  the  pulse 
104;  the  limbs  relaxed, 'but  moved  occasionally;  pupils,  me- 
dium size,  immobile;  respiration,  noisy.  The  urine  obtained 
from  the  bladder  was  highly  albuminous,  and  contained  many 
finely  granular  and  hyaline  casts.  In  the  evening  the  temper- 
ature was  98°,  and  the  condition  was  unchanged.  He  was 
thoroughly  purged  and  sweated  without  benefit.  He  died  on 
the  morning  of  the  28th,  never  having  roused  or  shown  any 
sign  of  consciousness.  An  autopsy  was  not  allowed,  nor  did 
the  coroner  order  one!  We  have  in  another  place  referred  to 
this  important  matter,  and  fully  agree  with  the  opinion  of  Dr. 
Osier  on  this  subject,  when  he  states:  "  I  do  not  think  that  the 
simple  presence  of  albumen  and  casts  should  absolutely  pre- 
clude the  administration  of  ether;  but  a  knowledge  of  their 
existence  should  increase,  if  possible,  the  precautions  taken, 
particularly  when  associated  with  the'  arterial  and  cardiac 
changes  so  common  in  chronic  Bright's  disease." 

Dr.  David  Cheever,  of  Boston,  believes  that  the  following 
operations  may  be  better  done  without  anaesthesia :  Extraction 
of  cataract,  tracheotomy  for  disease  and  paracentesis  thoracis. 

"Ether  has  been  accused*  (1)  of  killing  patients  by  asphyx- 
iation from  spasm  of  the  glottis;  (2)  of  killing  by  provoking 
pulmonary  mischief,  bronchitis,  pneumonia,  etc.;  (3)  of  para- 
lyzing the  respiratory  movements;  (4)  of  inducing  syncope. 
Syncope  does  certainly  occur  during  ether  administration,  al- 
though very  rarely.  Gosselin,  {Clin.  Chirurgicale  de  la  ChariU), 
cites  a  case  which  occurred  where  an  attempted  reduction  of  a 

♦  Buxton,  British  Medical  Journal,  September  19,  1885. 


254  AETIFICIAL  ANAESTHESIA. 

dislocated  thigh  was  proceeding.  Amidon  [New  York  Medical 
Record),  in  describing  the  condition,  believes  he  has  succeeded 
in  avoiding  this  danger,  by  injecting  small  doses  of  atropin. 
One  or  two  cases  have  since  been  recorded  {British  Medical 
Journal,  1878,  vol.  ii.,  p.  G02).  It  is  probably  doubtful  whether 
these  cases  are  due  to  ether  inhalation,  as  we  shall  see,  the 
heart  is  practically  uninfluenced  for  evil,  by  ether.  Ringer 
has  shown  how  ether  will  hardly  affect  the  heart-muscle  of 
frogs;  and  Wood,  after  noting  the  same  fact,  mentions  that, 
when  it  is  injected  into  the  veins  of  animals,  the  heart's  action 
remains  uninfluenced;  while  it  is  easily  demonstrable,  that 
when  the  mammalian  heart  is  watched,  artificial  respiration 
being  maintained,  it  will  be  found  practically  unaffected  by 
the  most  enormous  doses  of  ether.  When  death  does  occur, 
from  cessation  of  respiration,  the  heart  beats  for  a  considerable 
time.  Moreover,  the  heart-muscle  being  intact,  it  readily  re- 
sumes its  functions  when  artificial  respiration  is  performed. 
The  action  of  ether  upon  the  vaso-motor  system  has  been 
carefully  worked  out.  Arterial  pressure  is  always  increased  in 
ether  narcosis.* 

"  The  death  from  spasmodic  closure  of  the  glottis  ia  so  rare, 
as  practically  to  be  unimportant,  save  as  a  means  of  pointing  a 
moral ;  for  such  cases  are  certainly  due  to  the  administration 
of  too  powerful  a  blast  of  ether  to  a  timid  patient.  He  holds 
his  breath  as  long  as  nature  permits  him,  and  then,  with  the 
attempt  at  a  deep-drawn  inspiration,  inhales  a  supersaturated 
ether  atmosphere.  The  delicate  mucous  membrane  rebels,  and 
so  arises  the  spasm.  Even  in  such  cases,  admission  of  air  and 
pressure  on  the  chest  will  set  matters  right.  Such  accidents,  I 
think,  rarely,  if  ever,  occur  when  Clover's  inhaler  is  employed, 
by  one  accustomed  to  its  use. 

"Death  from  chilling  of  the  pulmonary  mucous  membrane, 
giving  rise  to  pneumonia,  or,  through  the  direct  irritation  by 
the  pungent  ether  vapor,  causing  tracheitis  and  bronchitis, 

*  Chloroform  Committee,  Boyal  Medical  and  Cliirurgical  Society.  Scientific 
Grants  Committee,  British  Jledical  Association.  Anstie,  "  Stimulants  and  Nar- 
cotics." Sansom  on  "Chloroform."  Bowditch  and  Minot  (^Boston  Medical  and 
Surgical  Journal,  1874;  quoted  hy  ^Vood). 


INTERNAL  ADMINISTRATION   OF   ETHER.         255 

does  in  a  certain  number  of  cases  occur.  Sedillot  (Peau, 
Clinique  Chirurgicale  a  I'Hopital  St.  Louis,  1882,  De  I'  Ancesthe- 
sie  Chirurgicale,  1882)  found,  experimentally,  that  dogs  get  pneu- 
monia when  ether  is  introduced  through  an  opening  in  the 
trachea.  Mr.  Lawson  Tait  {Practitioner,  March,  1876),  recog- 
nizing this  danger,  invented  an  apparatus  for  preventing  cold 
air  from  entering  the  lungs.  That  there  is  a  considerable  dan- 
ger of  these  occurrences  in  the  case  of  young  and  delicate 
children,  I  am  pretty  certain ;  and  I  should  be  glad  to  learn 
the  experiences  of  others  on  this  subject. 

"We  now  have  to  deal  with  the  last  and  most  important 
danger, — invasion  of  the  medullary  centre  and  stoppage  of 
respiration.  Ether,  there,  falls  short  of  the  ideal  as  an  anes- 
thetic, in  so  far  as  it  travels  beyond  merely  annulling  sensa- 
tion, and  attacks  vital  centres.  However,  considering  the 
great  volatility  of  ether,  and  that  the  advent  of  apnoea  is  her- 
alded by  marked  signs,  while  the  heart  remains  in  active 
function  even  after  apno3a,  we  have,  I  submit,  a  far  less  alarm- 
ing symptom  with  which  to  deal,  than  in  the  case  of  chloro- 
form apnoea."* 

Internal  Administration  of  Etlier. 

Exhibited  internally,  ether  is  an  excellent  diffusible  stimu- 
lant. It  sinks  in  water,  and  is  best  administered  mixed  with 
spermaceti  and  sugar,  or  in  mucilage  of  gum  arable ;  its  taste 
is  hot,  pungent  and  irritating,  and  when  placed  in  the  mouth, 
ears,  nose  or  rectum,  pain  is  produced.  It  dissolves  in  alco- 
hol, whiskey  or  brandy;  and  when  required  as  a  powerful 
stimulant,  as  in  fainting,  exhaustion  or  collapse,  this  is  an 
excellent  method  for  administering  it.  In  using  it  for  some 
time,  it  is  best  given  enclosed  in  capsules. 

Gout. — In  sudden  attacks  of  gout  in  the  stomach  or  intes- 
tines, a  useful  mixture  is  the  following : 

R     Spiritus  vini  gallici, 

^ther aa f |j.     M. 

SiG. — Dose,  one  teaspoonful  in  sugar  and  ice-water,  repeated  until 
relief  is  afforded. 

*  With  all  the  cases  of  death  from  ether  reported,  yet  how  small  they  numher  to 
the  millions  of  times  it  has  been  employed  without  loss  of  life  I 


256  ARTIFICIAL   ANESTHESIA. 

This  same  preparation  will  be  found  valuable  in  spasm  of 
the  stomach,  or  intestines,  or  heart.  Ether  has  been  proved  use- 
ful in  tape-worm,  alone,  or  combined  with  the  oleo-resin  of  the 
male  fern.  The  patient  must  live  upon  milk  and  a  little 
bread  for  one  day,  and  the  following  morning,  fasting,  take 
the  full  dose : 

li     Oleo  resinae  Filicis 5  83. 

^ther f  3;j. 

Mucilag.  acaciue,  ad.  ft f^ss-     M. 

This  is  to  be  repeated  in  three  hours ;  in  the  evening  food 
can  be  taken,  to  be  followed  with  a  full  dose  of  castor  oil  with 
twenty  drops  of  spirits  of  turpentine.  Some  French  authori- 
ties prefer  to  give  f^iss.  of  ether  alone,  administered  at  once, 
and  followed  in  two  hours  by  the  purgative. 

Ether  is  also  one  of  our  most  potent  remedies  in  hysteria, 
especially  when  associated  with  valerian,  asafcetida,  musk  or 
camphor.    In  the  first  with  the  fluid  extracts,  as  follows  : — 

R     ^ther. 

Valerian,  ex.  fluid aa f^j.     M. 

Sio. — A  teaspoonful  every  hour. 

In  the  second  it  is  mixed  with  the  tinctures  as  follows  : 

R     iEther. 

Tinct.  Asafoetidae, aa 5J. 

Mucilag.  acacice ^j.     M. 

SiG. — A  teaspoonful  every  hour  until  relieved. 

With  musk : 

R     Moschus Qij. 

^ther. 

Mucilag.  acaciae, aa f  Jj.     M. 

SiG. — A  teaspoonful  every  hour. 

With  camphor,  ether  is  not  only  useful  in  hysteria,  but 
all  forms  of  "  nervousness,"  in  dysmenorrhoea,  diarrhoea,  cholera, 
abnormal  sexual  excitement,  epilepsy,  hysterical,  puerperal  and 


COEYZA   AND   OBSTINATE   HOARSENESS.  257 

strychnic  convulsions.    Camphor  with   ether  is   best  adminis- 
tered as  follows : 

R     Viteili  ovi ,f  ij. 

Pulv.  campborae ,^ij. 

iEther ^ij.     M. 

Add  the  ether  to  the  camphor,  and  then  the  emulsion  ;  adminis- 
ter in  tablespoonful  doses  every  two  hours. 

Treatment  of  Sciatica  by  Subcutaneous  Injection  of 
Ether. 

We  first  gave  fifteen  drops,  which  was  followed  immediately 
by  great  relief  from  the  pain,  which  soon  passed  ofi".  The  injec- 
tion,in  increasing  doses  up  to  thirty  drops,  was  repeated  morning 
and  evening  for  three  days,  when  the  patient  was  discharged 
cured.  No  local  injury  resulted  ;  the  injections  were  made  in 
the  ordinary  superficial  method,  and  not  deep. 

Asthma. 

Inhalation  of  ether  is  very  valuable  in  relieving  spasmodic 
asthma,  and  obtaining  sleep  for  the  patient.  It  can  be  em- 
ployed alone,  or  associated  with  the  tincture  of  digitalis,  conium 
or  opium.  The  ordinary  dose  of  the  ether  is  from  ten  to  forty 
minims,  and  of  the  tincture  of  digitalis  or  opium  from  ten  to 
thirty  minims. 

The  Ether-Spray  in  Post-partum  Hemorrhag-e. 

The  use  of  ether-spray  in  post-partum  hemorrhage  has  been 
sometimes  successful  in  cases  in  which  the  usual  means  of  ar- 
resting the  flow  had  been  resorted  to  without  effect.  The  spray 
is  directed  on  the  abdominal  walls,  along  the  spine  and  over 
the  genitals. 

Coryza  and  Obstinate  Hoarseness. 

Drs.  Chapman  and  Physick,  recommended  the  vapor  of  equal 
parts  of  Hoffman's  anodyne  or  compound  spirits  of  sulphuric 
ether,  with  equal  parts  of  laudanum,  in  cases  of  recent  catarrh, 
in  coryza  and  obstinate  hoarseness,  by  inhalation.* 

*We  bave  also  employed  one-quarter  grain  of  sulphate  of  morphia  in  the  place 
of  the  laudanum,  making  a  more  elegant  preparation,  and  with  good  success. 


258  ARTIFICIAL  ANESTHESIA. 

Ether  as  an  Expectorant. 

Ether  has  been  found  useful  as  an  expectorant  in  the  sub- 
acute, or  chronic  form  of  bronchitis.  It  is  a  valuable  remedy. 
It  is  prescribed  in  five-  and  ten-minim  doses,  on  a  little  sugar, 
every  three  or  four  hours,  or  it  can  be  taken  by  inhalation  as 
follows :  The  cork  of  a  bottle,  half-filled  with  ether,  is  perfo- 
rated by  two  glass  tubes,  neither  being  immersed  in  the  ether. 
A  few  inspirations  through  the  tubes  every  hour  or  two  is  suf- 
ficient. As  the  remedy  is  also  a  diuretic  and  diaphoretic,  its 
utility  is  thereby  increased. 

Chorea. 

A  jet  or  hand  spray  of  sulphuric  ether,  free  from  alcohol, 
applied  to  the  spine  will  relieve  the  most  violent  spasmodic 
or  convulsive  attack  of  chorea,  with  the  subsequent  use  of 
Fowler's  solution,  five  to  ten  drops  three  times  a  day  in 
water,  and  occasional  application  of  the  galvanic  current  to 
the  spine. 

Nervous  Aphonia,  or  Temporary  Loss  of  Voice. 

The  vapor  of  ether  has  been  highly  recommended,  as  a  most 
valuable  remedy  in  hysterical  or  nervous  loss  of  voice.  It  has 
been  the  means  of  discovering  malingerers,  who  were  sup- 
posed or  stated  to  be  deaf  and  dumb,  and  who,  as  soon  as  they 
came  under  its  anaesthetic  influence,  were  able  both  to  hear 
and  speak. 

Diphtheritic  Angina,  or  Pseudo-Membranous 
Croup. 

Cases  of  diphtheritic  angina  have  been  treated  with  success 

by  inhalations  of  ether  and  steam,  with  the  internal  use  of 

brandy. 

Whooping'-Cough. 

Ether  alone  by  inhalation  is  extremely  useful  in  the  relief 
of  whooping-cough ;  and  a  combination  of  ether  sixty  parts, 
chloroform  thirty  parts,  and  oil  of  turpentine  one  part,  has  been 
found  a  successful  remedy.  The  patient  should  be  confined  to 
his  room,  making  him,  at  every  access  of  coughing,  place  before 


ETHER  SPRAY  ON  THE  VERTEBRAL  COLUMN.      259 

his  mouth  a  small  piece  of  clolh,  folded  several  times,  wet  with 
a  teaspoonful  of  the  mixture.  This  remedy  we  have  used  with 
most  gratifying  results,  at  the  same  time  employing,  between 
the  paroxysms,  extract  belladonna  and  quinine  sulph.  inter- 
nally, with  the  diluted  carbolic  acid  on  a  sponge  about  the 
patient's  room. 

Ether  in  Cardiac  Dyspnoea. 

It  is  stated  that  ether  has  been  found  a  remedy  for  cardiac 
dyspnoea,  the  sense  of  dyspnoea  being  relieved  by  the  internal 
administration  of  it  in  capsules,  containing  from  twenty  to  thirty 
drops,  or  by  small  sub-cutaneous  injections.  Large  doses  have 
the  same  effect  as  extreme  cold,  so  that  the  respiration  becomes 
slow  and  shallow.  The  same  action  is  produced  by  chloral, 
chloroform,  alcohol,  opium,  physostigmine,  muscarine,  gelse- 
mine,  aconite  and  veratrine. 

Etlier  in  Suspended   Animation  After    Delivery.* 

The  delivery  was  effected.  The  child  not  breathing,  it  was 
placed  in  a  bowl  of  warm  water,  sprinkled  on  the  chest  with 
cold  water,  and  Sylvester's  method  of  artificial  respiration  was 
practiced  upon  it.  At  the  end  of  10  minutes,  estimated  time, 
there  was  no  sign  of  life.  With  a  hypodermic  syringe,  between 
3  and  4  minims  of  ether  were  injected  deep  into  the  child's  arm. 
Within  a  minute  the  child  gasped,  and  in  2  or  3  minutes  it 
was  breathing  well  enough  to  enable  the  doctor  to  cease  the 
artificial  respiration. 

Ether-Spray  on  the  Vertebral  Column  in  Tetanus 
and  Chorea. 

The  local  application  of  the  ether-spray  to  the  spinal 
column,  so  warmly  recommended  some  time  ago  by  Lubelski 
and  Jaccoud,  seems  actually  an  effective  remedy  in  the  dis- 
eases mentioned.  Bonteillier  reports  in  Le  Progrls  M^dicale, 
40,  48,  a  case  of  traumatic  tetanus,  which  was  perfectly  cured 
by  the  ether-spray,   applied  at  first  every  two   hours,  then 

•By  N.A.Powell,  M.D. 


260  ARTIFICIAL   ANESTHESIA. 

every  five  hours  to  the  vertebral  column.  In  a  case  of  chorea, 
where  the  application  was  made  every  morning  and  night,  and 
lasted  from  three  to  five  minutes,  another  perfect  cure  was  ob- 
tained within  a  month.  It  need  not  be  added,  that  all  other 
known  remedies  were  previously  tried  in  vain. 

Ether    in    Mitigation  of    the    Agonies  of    Death. 

John  C.  Warren,  M.D.,*  says  : 

"  I  am  fully  aware  that  the  agony  in  the  dissolution  of  the 
bond  between  the  bodily  frame  and  its  spiritual  tenant,  is  not 
so  great  as  it  is  believed  to  be;  for,  having  questioned  a  great 
number  of  persons  passing  through  the  last  stage  of  earthly 
existence,  whether  they  suffered  pain,  the  answer  has  been 
almost  uniformly  in  the  negative;  and  on  inquiring  what  sen- 
sation was  experienced,  the  reply  has  been  such  as  to  lead  me 
to  consider  it  an  undefinable  sense  of  discomfort.  The  intel- 
lectual faculties  appear  to  be  so  clouded  and  confused,  that 
they  are  unable  to  take  cognizance  of  the  agitation  which  con- 
vulses the  physical  organization. 

"  There  are,  however,  exceptional  cases,  in  which  there  is 
great  bodily  suffering;  and  there  is  in  all  men  an  instinctive 
dread  of  the  pains  of  death.  If  we  find  the  means  of  pre- 
venting or  relieving  these  pains,  the  great  change  may  be 
viewed  without  horror,  and  even  with  tranquillity.  He  who 
would  experience  a  real  euthanasia  should  not,  however,  trust 
merely  to  the  virtues  of  ether,  but  should  also  have  settled  his 
accounts  with  this  world,  and  be  well  prepared  to  settle  those 
of  the  future. 

"  In  illustration  of  the  practice  alluded  to  may  be  men- 
tioned the  case  of  a  lady,  who  died  of  dysentery  in  the  sum- 
mer of  1847,  at  the  age  of  ninety.  She  had  been  my  patient 
more  than  forty  years ;  and  during  that  time,  besides  heavy 
domestic  calamities,  had  undergone  a  number  of  attacks  of 
pleurisy,  one  of  pericarditis,  a  severe  and  protracted  bleeding 

♦Etherization,  with  Surgical  ReniarkB  by  John  C.  Warren,  M.D.,  Emeritus  Pro- 
fessor ol  Anatomy  and  Surgery,  Univeraity  of  Cambridge,  Surgeon  at  Massacliusetts 
General  Hospital,  Boston.     William  D.  Ticknor  &  Co.,  Boston,  1847,  pp'.  70. 


INTOXICATION   FROM   ETHER.  261 

from  the  stomacli,  with  symptoms  of  malignant  disease  of  this 
organ.  She  was  once  dangerously  poisoned  by  eating  par- 
tridge ;  moreover,  by  a  fall  she  had  a  fracture  of  the  neck  of 
the  thigh-bone^  and  soon  after  her  restoration  was  attacked 
with  senile  mortification  of  the  foot,  from  which,  having  suf- 
fered months  of  intense  pain,  she  wholly  recovered. 

"Very  temperate  in  her  eating  and  drinking,  and  of  a  re- 
ligious character,  she  was  cheerful,  notwithstanding  all  these 
visitations;  appeared  to  enjoy  life  more  as  she  grew  older, 
went  out  freely,  and  made  two  or  three  excursions  into  the 
country,  within  a  few  weeks  of  her  last  illness. 

"  The  dysenteric  attack,  which  terminated  her  career,  ac- 
companied with  symptoms  of  unusual  severity,  was  only  re- 
lieved for  a  very  short  time  by  the  use  of  opium.  After  more 
than  two  weeks  of  illness,  violent  pain  occurred  in  one  of  the 
feet,  with  discoloration,  ending  in  gangrene.  The  pain  of 
mortification  suddenly  ceasing  under  the  use  of  opium,  that  of 
the  abdomen  returned,  with  convulsive  twitchings  of  the 
limbs  ;  and  other  remedies  failing  to  mitigate  these  symptoms, 
inhalation  of  ether  was  employed  with  perfect  relief. 

"  From  the  first  inhalation  to  the  period  of  her  death,  five 
days  elapsed,  during  which  a  considerable  number  of  ether- 
izations were  used,  and  with  such  effect  that,  as  soon  as  any 
suffering  occurred,  she  desired  ether.  In  the  intervals,  her 
mind  was  clear;  she  arranged  such  worldly  matters  as  re- 
mained unsettled,  received  the  consolations  of  religion,  and 
finally,  under  ethereal  influence,  her  spirit  imperceptibly  took 
its  flight." 

Ether  Intoxication. 

"  A  few  years  ago  there  was  published  in  the  Reporter'^  the 
'  confessions  of  an  ether  inhaler,'  a  member  of  our  own  profes- 
sion, for  whom  it  subsequently  became  our  sad  duty  to  sign  a 
certificate  of  insanity. 

"  We  are  reminded  of  this  by  a  paper  in  the  London  Iledical 
Record,  by  Dr.  Ewald,  of  Berlin,  on  a  somewhat  similar  case. 
It  is  that  of  a  man  aged  thirty-two,  who  was  lately  admitted 

*  Medical  and  Surgical  Eepcrter, 


262  ARTIFICIAL  ANiESTHESIA. 

into  the  Charitfe  Hospital,  under  Professor  Frerichs,  suflTering 
from  general  debility  and  trembling  of  the  muscles.  On  inquiry, 
it  was  found  that  he  was  notorious  in  Berlin  for  intoxicating 
himself  with  ether,  his  abuse  of  which  had  reduced  him  to  his 
present  miserable  condition.  He  was  originally  temperate,  and 
had  been  a  university  student,  passing  all  his  examinations 
with  credit;  he  was,  however,  of  a  mystical  turn  of  mind. 
Unfortunately,  a  little  more  than  nine  years  ago,  there  fell  into 
his  hands  a  medico-popular  treatise,  in  which  the  use  and 
effects  of  ether,  used  medicinally,  were  described,  and  a  glowing 
account  was  given  of  its  effect  in  quickening  the  creative  power 
of  the  mind.  He  procured  about  two  or  two  and  a  half  ounces 
of  sulphuric  ether,  and  inhaled  it  from  a  handkerchief;  the 
result  being  to  produce  insensibility  for  about  a  quarter  of  an 
hour,  during  which  time  he  imagined  that  he  lived  for  an  in- 
definite time,  and  traveled  over  whole  worlds.  This  condition, 
however,  he  was  not  again  able  to  induce  in  so  high  a  degree. 
Becoming  gradually  more  and  more  addicted  to  his  habit,  he 
no  longer  confined  himself  to  indulging  himself  in  his  own 
room,  but  with  his  etherized  handkerchief  before  his  face,  he 
wandered  through  the  streets,  purchasing  small  quantities  of 
ether  at  the  druggists'  shops,  until,  at  last,  he  became  so  great 
a  nuisance  to  them  that  many  of  them  closed  their  doors  against 
him.  He  was  also  turned  out  of  his  lodgings,  on  account  of 
the  annoyance  produced  by  the  smell  of  his  breath,  and  became 
a  houseless  wanderer,  reduced  in  means  and  in  health.  In  the 
hospital  there  was  no  indication  that  his  mind  was  affected; 
his  memory  was  not  impaired;  his  style  of  speaking  was  fluent. 
On  one  occasion  an  attempt  was  made  to  produce  complete 
anaesthesia.  For  this  purpose  more  than  seven  ounces  were 
required ;  the  ether  being  given  by  an  inhaler,  and  loss  being 
prevented  by  closing  in  the  apparatus  with  cotton-wool.  No 
sooner,  however,  was  the  inhalation  stopped,  than  the  state  of 
insensibility  passed  off.  He  was  then  allowed  to  take  the  ether 
in  his  own  way,  by  inhaling  it  from  a  handkerchief.  Given  in 
this  way,  it  produced  a  stage  of  excitement,  during  which  he 
danced  about  the  room,  talked  nonsense,  and  appeared  much 
pleased,  but  there  was  no  true  narcotism.      It  was  not  thought 


CI-IEONIC   INTOXICATION   FROM    ETHER.  263 

justifiable  to  subject  him  to  other  experiments  with  ether,  as  it 
was  desirable  to  break  through  his  habit.  It  is  interesting,  that 
his  susceptibility  to  the  action  of  cannabis  indica  was  not  im- 
paired. This  drug  was  given  as  a  substitute  for  ether,  and  on 
the  first  occasion,  too  large  a  dose  having  been  given,  the  result 
was  the  production  of  phantasms,  such  as  are  induced  by  the 
smoking  of  hasheesh.'' 

The  late  Dr.  Morgan,  of  Dublin,  states  that  ether  is  em- 
ployed in  certain  portions  of  Ireland  as  a  substitute  for 
whiskey. 

A  case  has  come  under  the  writer's  notice,  in  which  a  patient 
began  the  use  of  sulphuric  ether  in  teaspoonful  doses,  as  a 
nervine  ordered  by  a  physician,  and  ultimately  increased  the 
dose  to  one  pint  per  day.  When  informed  of  its  injurious 
character,  she  had  lost  her  appetite,  and  suffered  gastric  dis- 
turbance ;  she  gradually  diminished  the  quantity  and  was  able 
to  give  it  up  after  a  month  or  two.  The  only  effect  it  had  upon 
her  was  to  give  her  apparent  strength  to  go  on  with  her  teaching 
of  music.  Large  quantities  of  ether  have  been  taken  internally, 
and,  so  far  as  we  have  been  able  to  learn,  no  death  has  yet 
occurred  from  its  use  in  this  way. 

Chronic  Intoxtcation  feom  Ether.* — The  patient,  a 
woman  of  forty-eight  years,  had  been  in  the  habit  of  swallow- 
ing after  each  meal  a  lump  of  sugar  wetted  with  sulphuric  ether, 
to  relieve  a  difficulty  in  digestion.  During  the  space  of  two 
months  aud  a  half  preceding  her  admission  to  the  hospital 
de  La  Piti6,  she  took,  in  this  manner,  a  total  of  180  grammes 
(nearly  six  ounces).  When  she  had  continued  the  practice  for 
about  seven  weeks,  trembling  of  the  hands  commenced.  A 
week  later  she  began  to  feel  severe  pains  in  the  lower,  front 
part  of  the  chest,  and  between  the  shoulder-blades.  She  also 
suffered  from  vomiting  of  a  whitish  watery  fluid,  on  rising  in  the 
morning.  In  a  week  more  her  gait  became  unsteady,  and  she 
suffered  from  trembling  of  the  toes,  cramps  in  the  calves,  and 
prickling  sensations  in  the  feet. 

Upon  admission  to  the  hospital,  she  presented  all  the  above 
symptoms.    The  pain  resembled  that  which  would  be  caused 

*  Martin.     Gazette  dea  Hdpitccux,  May  10,  1870. 


264  ARTIFICIAL   ANiESTHESIA. 

by  two  blisters,  of  eight  or  ten  centimetres  in  diameter,  the 
one  placed  a  little  above  the  epigastrium,  the  other  at  the  same 
level  on  the  back.  It  was  intermittent,  and  was  excited  by  any 
sort  of  aliment.  There  were  regular  slight  twitchings  in 
certain  portions  of  the  limbs.  The  strength  of  the  hands  was 
not  diminished.  Almost  continual  buzzing  in  the  ears ; 
muscse  volitantes  occasionally,  usually  followed  by  a  brief 
attack  of  frontal  headache.  Pupils  slightly  enlarged.  Sleep 
undisturbed.  No  fever.  Soft  souffle  at  base  of  heart,  and  in 
vessels  of  neck,  accompanying  the  first  sound.  No  other 
important  symptoms. 

An  emetic  at  entrance,  a  daily  bath,  a  little  opium  at  night, 
and  abstinence  from  ether,  constituted  the  entire  treatment. 
Recovery  was  complete  at  the  end  of  two  weeks. 

Vivisections. 

An  excellent  use  of  ether  may  be  made  in  regard  to 
animal  vivisections.  Ether  enables  us  to  lull  the  sensibilities 
of  the  victim,  tranquilly  pursue  the  natural  workings  of  the 
internal  organs,  and  the  changes  which  take  place  from  experi- 
mental applications;  while  the  student  of  gurgery  can  accustom 
himself  to  those  gushes  of  the  vital  fluid,  which,  in  the  human 
body,  are  viewed  with  so  much  terror  by  the  unpracticed. 
Animals  of  any  size  may  be  etherized  in  a  box,  or  by  covering 
the  head  with  an  India-rubber  sack,  into  which  a  mixture  of 
ether  and  atmospheric  air  is  forced. 

"Vivisections  with  Ether  and  Chloroform. 

Prof.  SchifF,  of  Geneva,  states:  "In  our  experiments,  that  is, 
in  more  than  three  thousand  cases,  we  have  adopted  etherization 
with  a  view  to  preserve  the  life  of  animals ;  and  that,  with 
few  exceptions,  indicated  elsewhere  (Memoir  on  the  Laryn- 
geal Nerve),  not  a  single  case  of  death  occurred.  On  the 
other  hand,  chloroform  has  cost  us  a  considerable  number  of 
animals,  when  I  have  wished  to  push  anaesthesia  to  its  ultimate 
stage." 

In  our  experiments  we  have  proven,  that  even  bromide  of 
ethyl  is  safer  in  making  vivisections,  than  chloroform. 


FOEMIC   ETHER.  265 


CHAPTER    XVI. 

Ethers  which  have  Anaesthetic  Properties — Acetic  Ether — Experi- 
ments by  Dr.  H.  C.  Wood  on  Animals,  etc — Formic  Ether — Byas- 
son's  Conclusions  in  regard  to  it — Hydriodic  Ether — Properties- 
and  objections  to  its  use — Methylic  Ether — Dr.  Richardson's  Ex- 
periments with  it — Bichloride  of  Methylene — Observations  upon 
it  by  Dr.  Jones,  of  Cork,  Dr.  Taylor  and  Spencer  Wells,  of  London 
— Ethyl  Iodide — Ethylene  Bromide — Iodoform — Carbon  Dichlo- 
ride — Bromoform — Tetrachloride  of  Carbon — Butyl  Chloride — 
Chloride  and  Bichloride  of  Ethylene — Ethyl  Nitrate — Iodide  of 
Methyl — Amyleue — Chloral  Hydrate — Acetic  Aldehyde . 

Acetic  Etlier  (C2H5C2H3O2). 

Acetic  etlier  is  colorless,  and  has  au  agreeable  odor  and  burn- 
ing taste.  Specific  gravity  0.89;  boiling  point  165.2°  F.  If 
kept  in  contact  with  air,  and  in  the  presence  of  water,  free 
acetic  acid  is  formed.  According  to  Dr.  H.  C,  Wood,  in  pigeons 
and  rabbits  it  produces  perfect  unconsciousness  without  as 
much  previous  struggling  as  when  sulphuric  ether  is  used, 
and  has  the  advantage  over  that  compound  of  being  less 
inflammable ;  on  the  other  hand,  its  volatility  is  less.  No 
experimenter  has  employed  this  ether  on  man  to  produce 
ansesthesia. 

Formic  Ether  (C^H.CHO^). 

Formic  ether  is  a  colorless  liquid,  recalling  the  odor  of  rum, 
and  having  an  agreeable  taste.  Specific  gravity  0.915  ;  density 
62.8;  boiling  point  127.8°  F.  It  dissolves  in  nine  parts  of 
water,  and  all  proportions  in  alcohol,  ether,  fixed  and  volatile 
oils.  Byasson,  made  some  experiments  with  it  on  animals,  and 
found  that  this  ether  decomposed  into  alcohol  and  alkaline 
12 


266  ARTIFICIAL  ANAESTHESIA. 

formiates  througli  the  alkalies  of  the  blood.    When  inhaled,  it 
lowers  the  temperature  and  induces  asphyxia. 

Hydriodic  Ether  (C^HJ). 

Hydriodic  ether  is  a  colorless,  non-inflammable  liquid,  having 
a  peculiar  ethereal  odor  and  taste,  soluble  in  alcohol,  and 
nearly  insoluble  in  water.  It  boils  at  158.5°  F. ;  specific  gravity 
of  liquid  at  32°,  1.9755.  Exposed  to  the  air  and  light  it  liberates 
iodine  and  becomes  brown,  which  irritates  the  nostrils  and 
causes  lachrymation,  and  is  sometimes  employed  by  inhalation 
to  bring  the  system  under  the  influence  of  iodine  in  chronic 
bronchitis  and  phthisis, 

MetliyUc  Ether  (CH3)0,. 

Methylic  ether  is  a  colorless  and  very  inflammable  gas, 
heavier  than  air,  of  an  oppressive  odor.  It  is  soluble  in  water, 
wood-spirit,  alcohol  and  ether.  A  saturated  solution  in  ether, 
at  82°  F.,  has  been  recommended  by  Dr.  B.  W.  Richardson, 
who  experimented  upon  himself,  and  found  that  there  was  no 
preliminary  spasm  excited  in  the  larynx,  or  elsewhere.  The 
pulse  arose  to  ninety-six,  and  the  ansesthesia  was  perfect;  yet 
he  objected  to  it  because  it  rapidly  volatilizes  from  its  solution, 
and  on  account  of  its  unpleasant  odor.  Dr.  Carter  says:  "In 
Dr.  Richardson's  own  hands  I  have  seen  the  various  (new) 
ethers  act  perfectly  well,  producing  complete  unconsciousness 
and  relaxation  of  muscle  without  either  struggling  or  sickness, 
and  without  unpleasant  symptoms  of  any  kind  ;  but  I  cannot 
judge  how  far  such  results  may  have  been  due  to  the  qualities 
of  the  agents  employed,  how  far  due  to  specially  skillful  or 
careful  administration,  or  how  far  to  the  state  of  the  patients 
themselves."* 


*  In  specific  gravity,  boiling-point,  etc.,  \re  have  followed  Prof.  Wm.  Allen 
Miller's  "  Elements  of  Chemisti-y,"  Part  III.,  Organic  Chemistry  (London :  Long- 
man, Green,  Reader  &  Dyer,  fourth  edition,  18G9),  or  Prof.  Maisch's  National  Dis- 
pensatory (Philadelphia-  H.  C.  Lea,  1879). 


BICHLORIDE  OF  METHYLENE.  267 

Bichloride  of  Methylene  (CHjOlj)  — An  Anaesthetic. 

Preparation*— By  acting  on  chloroform  with  nascent 
hydrogen. 

CHClgX  n,=CH3Cl,X  HCl. 
Boiling  point,  40°  C.  (104°  F.).* 

Characters.— A  colorless,  volatile  liquid  with  smell  like 
chloroform. 

This -an aesthetic  was  carefully  studied  by  Dr.  Richardson, 
who  gave  it  a  very  high  character.  This  was  1867.  His 
views  were  soon  called  in  question  by  Nussbaum  in  Ger- 
many, and  Tourdes,  Hept  and  Pean  in  France,  while  Spencer 
Wells  took  up  the  subject  and  defended  it  in  England.  For 
years  it  was  fully  tested  at  Moorfields  Ophthalmic  Hospital ; 
but  two  deaths  occurred  without  any  indication  of  danger 
from  the  state  of  the  pulse  or  heart.  In  1879  we  had  it  pre- 
pared by  Dr.  W.  H.  Greene,  and  even  with  all  his  care  the 
specimen  contained  chloroform,  and  was  very  costly.  It 
was  then  tested  by  the  late  Dr.  Washington  Atlee,  the  article 
having  been  obtained  through  Spencer  Wells ;  but  Atlee 
did  not  find  it  as  satisfactory  in  ovariotomy  as  his  mix- 
ture of  ether  and  chloroform.  Subsequently  more  deaths 
occurred  from  its  use.f  Spencer  Wells  stated  at  the  meet- 
ing of  the  British  Medical  Association,  1877:  "Whatever 
may  be  its  chemical  composition,  whether  it  is  chloro- 
form .mixed  with  some  spirit  or  ether,  or  whether  it  is  really 
bichloride  of  methylene,  I  am  still  content  with  the  eflfects 
of  the  liquid  sold  under  that  name."  It  is,  we  believe, 
still  employed  in  the  "  Samaritan  Free  Hospital "  of  London 
by  the  officers  in  charge ;  but  Spencer  Wells  has  retired  from 
the  institution  where  he  achieved  such  wonderful  results.  The 
operation  of  ovariotomy  has  been  improved  upon  by  Mr.  Law- 
son  Tait,  under  the  use  of  ether,  namely,  one  hundred  and 
thirty-nine  consecutive  operations  without   a  single   death. 

*  Action. — Like  that  of  chloroform,  hut  more  rapid,  thotigh  a  larger  quantity  is 
required.  It  depresses  the  action  of  the  heart  more  than  chloroform,  and  death  is 
even  more  sudden  and  without  warning  symptoms. 

t  See  list  of  deaths,  with  details,  p.  270. 


268  ARTIFICIAL  ANAESTHESIA. 

Four  years  ago  MM.  "Regnauld  et  Villejeau  {Journ.  de  Pharm. 
et  de  Chem.,  1878)  underlook  a  research  which  has  recently 
been  completed,  and  which  led  them  to  the  following  results: 
that  the  commercial  methylene,  obtained  through  agents  ac- 
credited by  Sir  Spencer  Wells,  and  therefore  genuine,  was  a 
mechanical  mixture  composed  of  four  parts  of  chloroform  and 
one  of  methylic  alcohol.  In  some  comparative  experiments 
they  administered  the  two  agents,  finding  that  while  the  com- 
mercial agent  behaved  precisely  like  chloroform,  the  genuine 
methylene  bichloride  produced  choreiform  and  epileptiform 
convulsions. 

Bichloride  of  methylene  was  discovered  in  1840,  but  was  in- 
troduced by  Dr.  B.  W.  Kichardson.  For  some  years  it  has 
received  the  fullest  trials  at  Moorfields  Ophthalmic  Hospital, 
London,  Avhere  they  now  use,  almost  exclusively,  sulphuric 
ether.  Within  the  two  years'  trial  of  the  bichloride  of  methy- 
lene in  the  hospital  above  referred  to,  two  deaths  occurred  with- 
out any  indication  of  danger  from  the  state  of  the  pulse  or 
heart ;  in  the  last  instance  of  death,  it  occurred  from  the  exhi- 
bition of  one  drachm  and  a  half  of  methylene  to  a  healthy 
sailor,  aged  twenty-seven  years.  It  has  been  employed,  not 
only  in  short  operations,  but  also  in  such  operations  as  ovari- 
otomy. "  With  this  agent.  Dr.  Jones,*  of  Cork,  has  had  con- 
siderable experience,  having  used  it  constantly  for  all  minor 
operations  in  hospital  and  private  practice  for  over  seven  years. 
Hard  drinkers  or  old  tipplers  bore  this  form  of  anaesthetic 
badly,  and  on  some  occasions  he  has  been  alarmed  and  com- 
pelled to  desist  from  its  administration ;  he  also  found  it  to 
be  dangerous  in  old  cases  of  chest  affection.  His  mode  of  ad- 
ministration was  in  a  conical  gauze  bag  lined  with  flannel,  and 
containing  a  small  sponge." 

Mode  of  Preparation. — Bichloride  of  methylene  is  both 
diflicult  and  expensive  to  make.  It  is  prepared  by  heating  one 
part  of  methylic  alcohol,  two  parts  of  common  salt  and  three 
parts  of  sulphuric  acid,  and  passing  the  gas  through  water  into 
a  glass  globe,  into  which  chlorine  gas  is  conducted  at  the  same 

*  Medical  Responsibility  in  the  Choice  of  Ansesthetlcs.  By  H.  M.  Jones,  M.D., 
Surgeon  to  Corli  Ophthalmic  Hospital.     Cork,  1876. 


BICHLORIDE   OF   METHYLENE.  269 

time.  The  globe  is  drawn  out  below  so  as  to  form  a  thin  tube, 
which  passes  into  one  tubulure  of  a  Wolfs  bottle,  the  second 
tubulure  being  connected  by  means  of  a  bent  glass  tube  with  a 
second  Wolfs  bottle,  this  second  bottle  being  placed  in  ice ; 
the  other  tubulure  of  this  second  bottle  is  connected  with  a 
flask  cooled  by  means  of  a  freezing  mixture.  The  liquid  which 
is  condensed  in  the  Wolfs  bottles  is  chiefly  chloroform,  while 
that  in  the  flask  is  almost  pure  methylene  dichloride,  or  bi- 
chloride of  methylene. 

Bichloride  of  methylene  is  a  colorless  fluid,  having  an  odor 
much  like  that  of  chloroform.  It  is  pleasant  to  inhale  as  a  va- 
por, and  produces  very  little  irritation  of  the  fauces  and  air- 
passages.  Its  specific  gravity  is  1.344,  and  its  boiling  point 
105°  F.  From  its  easier  evaporation,  it  requires  freer  admin- 
istration than  chloroform  ;  and  because  of  its  denser  vapor,  less 
quantity  than  ether. 

Bichloride  of  methylene  has  no  action  on  test-paper,  is  soluble 
in  alcohol  and  ether  and  is  frequently  mixed  with  other  agents 
in  England,  this  being  easily  accounted  for  by  the  difficulty  in 
making  it,  and  its  cost.  These  various  mixtures  give  us  a  clue 
to  its  unequal  character  in  regard  to  safety,  in  the  hands  of  dif- 
ferent experimenters.  Its  vapor  has  a  density  of  3.012,  and 
burns  with  a  bright  flame.  Six  deaths  have  occurred  from 
its  use.  There  is  no  doubt  that  it  has  many  of  the  dan- 
gerous qualities  of  chloroform,  as  it  belongs  to  the  same  chemi- 
cal family,  and  death  results  from  syncope,  with  dilated 
pupils. 

The  bichloride  of  methylene  was  employed  in  the  Samaritan 
Free  Hospital,  of  London ;  and  the  officer  in  charge  of  the  an- 
aesthetic states  it  to  be  very  satisfactory.  Junker's  form  of  ap- 
paratus is  used  for  its  administration.  The  mortality  from  this 
agent  is  two  in  ten  thousand,  or  one  to  five  thousand. 

As  we  have  stated  above,  the  strongest  advocate  for  the  bichlo- 
ride of  methylene  or  chloromethyl  is  Sir  Spencer  Wells,* 
who  believes  that  with  this  agent  he  has  had  all  the  advantages 
of  complete  anaesthesia,  with  fewer  drawbacks  than  any  other  j 
this  is  his  experience  of  five  years,  and  of  three  hundred  and 

*  Meeting  of  British  Medical  Association,  1877. 


270  ARTIFICIAL   ANiESTHESIA. 

fifty  serious  operations.  He  gives  it  diluted  with  air  by  Jun- 
ker's apparatus,  and,  from  hia  doubts  of  its  composition,  we 
suspect  what  he  employs  to  be  a  mixture  of  methylic  alcohol 
and  chloroform.  These  are  his  own  words:  "  Whatever  may 
be  its  chemical  composition,  whether  it  is  chloroform  mixed 
with  some  spirit  or  ether,  or  whether  it  is  really  bichloride 
of  methylene,  I  am  still  content  with  the  effects  of  the  liquid 
sold  under  that  name." 

Dr.  Taylor*  also  states  that  "a  mixture  of  chloroform  and 
ether  has  been  sold  as  bichloride  of  methylene.  On  shaking 
this  mixture  with  water,  the  chloroform  is  separated  and 
sinks."  He  reports  three  deaths  from  this  agent,  and  the  alle- 
gation, therefore,  that  the  vapor  possesses  any  greater  degree 
of  safety  than  chloroform  in  surgical  practice,  is  not  supported 
by  facts. 

Death  from  the  Bichloride  of  Methylene. 

Case  1. — A  death  from  bichloride  of  methylene  took  place 
at  the  Ipswich  Hospital,  England,  which  affords  a  remarkable 
illustration  of  the  relative  safety  of  that  drug  and  of  ether. 
The  patient  was  fifty-six  years  of  age,  and  was  to  have  had  a 
necrosed  bone  removed  from  his  leg.  He  was  first  given  the 
methylene,  which  was  changed  for  ether,  for  some  cause  which 
is  not  stated,  but  which  may  have  been  some  alarming  symp- 
tom produced  by  the  methylene.  Having  taken  the  ether  with 
safety  until  auEesthesia  was  obtained,  the  operation  was  pro- 
ceeded with  ;  but,  the  patient  being  allowed  to  wake  too  soon, 
the  methylene  was  again  resorted  to ;  in  fifteen  seconds  he  was 
dead.  No  post-mortem  examination  was  made,  but  some  in- 
genious person  hazarded  a  guess  that  there  had  been  unob- 
served apoplexy;  and  the  jury,  happy  at  any  alternative  ex- 
cept condemnation,  adopted  the  hint,  and  voted  the  death  ac- 
cidental, and  the  medical  officers  free  of  all  blame.  A  most 
unsatisfactory  case  in  all  its  aspects,  and  one  which  should 
please  the  medical  ofiicers  inculpated  less  than  any  one  else  ; 
such  a  fatality  may  be  hidden  away  by  such  a  verdict,  but  no 

*  On  Poiaona,  op.  cit,  p.  629. 


DEATHS   FROM   METHYLENE   BICHLORIDE.         271 

one  can  be  satisfied,  without  evidence,  that  the  case  was  not 
one  of  anaesthetic  manslaughter. — Medical  Press,  London. 

Case  2.  Pharmaceutical  Journal,  1871,  p.  875.  Male,  set. 
forty.  Given  during  an  operation  on  the  eye ;  result,  death  in 
five  minutes.     Post-mortem,  congestion  of  the  lungs. 

Case  3.  Pharmaceutical  Journal,  1871,  p.  875.  Male.  In- 
haled 3iss;  result,  death  rapid,  Pos^mor/effi,  no  special  post- 
mortem appearances. 

Case  4.  Lancet,  October  23d,  1869,  p.  582.  Mr.  Marshali. 
Male,  set.  thirty-nine  ;  ^  iss.  The  man  was  sitting  in  a  chair 
during  the  time  of  administration,  and  preparing  for  an  opera- 
tion. Symptoms,  pupils  slightly  dilated;  no  stertor  or  lividity 
of  countenance ;  result,  death. 

Case  5.  One  of  the  most  painful  cases  of  death  from  the 
vapor  of  methylated  ether  occurred  in  the  Birmingham  Hos- 
pital, England,  under  Mr.  Tait.  A  patient  was  about  to 
undergo  the  operation  of  ovariotomy  ;  five  drachms  of  methy- 
lated ether  in  vapor  were  administered  to  her  on  a  fold  of  a 
towel,  by  the  resident  medical  officer.  The  pulse  suddenly 
stopped,  the  pupils  became  dilated,  and  respiration  ceased ;  all 
efforts  at  restoration  were  fruitless.  On  inspection  the  heart 
and  all  the  other  organs  were  healthy,  except  the  ovary. — Lan- 
cet, July  5th,  1873,  p.  23. 

"  Kappeler,  says,  that  experience  shows  it  to  be  as  dangerous,, 
if  not  more  so,  as  chloroform,  and  furnishes  a  list  of  nine  cases 
of  death  from  its  use.  Unfortunately,  I  have  not  had  a  copy 
of  Kappeler's  work  at  my  disposal  ;  but  in  looking  over  the 
details  of  cases  published  in  the  journals  to  which  I  have 
had  access  (ilfed  Times  and  Gaz.,  1869,  ii.  p.  524;  Lancet,  1869, 
p.  582 ;  British  Medical  Journal,  Sept.  1871 ;  Pharmaceutical 
Journal,  1871,  p.  875,  two  cases ;  British  Medical  Journal, 
August.  1872  ;  Lancet,  1873,  i.  p.  23 ;  Ibid.,  1877,  ii.  p.  26),  I 
have  found  that  in  several  of  them  doses  of  a  drachm  and  a 
half  caused  death,  and,  judging  from  the  symptoms,  it  must  be 
undoubted  that  death  ensued  in  some  of  them,  at  least  from 
cardiac  paralysis.  The  experiments  made  by  the  British  Com- 
mittee, on  frogs,  show  that  the  heart  becomes  slowed  and  is  soon 
stopped,  and  that  the  heart  was  affected  the  same  as  by  chloro' 


272  AETIFICIAL   ANiESTHESIA. 

form,  the  first  sign  of  paralysis  being  the  distension  of  the  right 
ventricle.  Even  were  it  not  certified  by  the  above  Com- 
mittee that  it  affects  the  heart  like  chloroform,  the  fact  of 
death  occurring  after  doses  but  ordinarily  sufBcient  to  pro- 
duce aniesthesia  is  sufiicient  to  impress  every  one  with  the 
truth  that  it  acts,  like  chloroform  and  ethyl  bromide,  wholly 
out  of  proportion  to  the  dose.'" — {Beichert.) 

Dr.  Dudley  Buxton  writes :  "  I  believe  I  am  accurate  in 
saying  Sir  Spencer  Wells  obtains  his  methylene  from  only 
one  source,  and  I  am  unaware  that  it  is  to  be  got  elsewhere 
in  England.  The  methylene  so  obtained  was  tested  clini- 
cally, and  found  to  produce  the  usual  anajsthetic  trance.  It 
was  then  submitted  to  chemical  analysis,  and  a  result  ob- 
tained which  showed  it  to  be  composed  of  four  parts  methy- 
lated chloroform  diluted  by  one  part  of  methylic  alcohol. 
Subsequently  these  investigators  prepared  some  genuine  bi- 
chloride of  methylene  (CjHgCl,)  which  they  administered  to 
animals,  with  the  result  that  no  ansesthesia  appeared,  but  in 
its  place  wild  excitement,  convulsions  and  death." 

Methylene  was  carefully  studied  by  Dr.  Richardson,  who 
gave  it  a  very  high  commendation.  His  views  were  early 
called  in  question  by  Nui-sbaum  in  Germany,  and  Tourdes 
and  Hept  and  Pean  in  France,  while  Sir  Spencer  Wells  took 
up  the  cudgels  in  its  defence.  Subsequently,  several  deaths  oc- 
curring, the  belief  in  this  agent  became  shaken.  It  was  further 
objected  by  the  Anaesthetic  Committee  of  the  British  Medical 
Association  that  the  methylene  was  probably  not  a  simple  body. 
Six  years  ago,  MM.  Regnauld  et  Villejeau  {Journ.  de  Pharm.  et 
de  Chim.,  1883)  undertook  a  research  which  has  recently  been 
completed,  and  which  led  them  to  the  following  results  :  that  the 
commercial  methylene  obtained  through  agents  accredited  by 
Sir  Spencer  Wells,  and  therefore  genuine,  was  a  mechanical 
mixture  composed  of  four  parts  of  chloroform  and  one  of  methy- 
lic alcohol.  Their  proofs  we  cannot  detail.  They  next  investi- 
gated true  methylene  dichloride — that  is,  methylene  bichloride 
— a  substance  very  difficult  to  prepare  pure,  and  very  costly.  In 
somecomparative  experiments  they  administered  the  two  agents, 
finding  that,  while  the  commercial  agent  behaved  precisely  like 


HYDRIODIC   ETHER.  273 

chloroform,  the  genuine  methylene  bichloride  produced  chorei- 
form and  epileptiform  convulsions.  Unless  any  flaw  can  be 
shown  in  the  work  of  these  gentlemen,  methylene  cannot,  we 
take  it,  be  accredited  with  any  virtues  greater  than  belong  to 
the  long-known  mixtures  of  chloroform  and  alcohol.  Obvi- 
ously, no  further  discussion  on  our  part  is  needed. 

Ethidene  and  amylene  have,  unfortunately,  been  discred- 
ited, as  deaths  have  occurred  during  their  use.  Those  attrib- 
uted to  amylene  are,  according  to  M.  Pean,  attributable  to 
causes  other  than  the  agent  employed ;  and  the  same  may  well 
be  said  of  several,  notably  the  one  recorded  by  Mr,  Clover 
{British  Medical  Journal,  1878),  with  regard  to  the  fatalities  of 
ethidene.  The  behavior  of  the  group  before  us  reveals,  in  a 
striking  degree,  the  working  of  laws  which  connect  their  be- 
havior towards  the  organism  with  the  molecular  weight  of  the 
agent.  Thus,  Dr.  Richardson,  comparing  a  number  of  them, 
says:  "There  appears  to  be  reason  for  the  belief  that  the 
lethal  energy  of  an  anaesthetic  is  clearly  related  to  the  molec- 
ular weight  of  the  substance,  increasing  directly  as  its  weight 
increases."  However,  in  summing  up  the  case  of  the  various 
members  of  the  carbon-series  in  which  chlorine  occurs,  we  think 
we  must  admit  that,  as  far  as  the  evidence  is  now  before  us, 
they  are  all  dangerous  anaesthetics. 

"  Hydrioclic  Ether  or  Etliyl  Iodide, 

also  used  by  Nunnelly  {he.  cit.,  p.  324),  was  found  to  be  so  dan- 
gerous as  to  entirely  preclude  its  use  in  medicine  for  anaesthetic 
purposes ;  and  he  states,  that  whatever  anaesthetic  property  it 
might  possess  (and  this  is  not  insignificant),  it  never  could  be 
employed  in  practice,  as  its  action  is  so  very  deleterious ;  for 
out  of  the  four  animals  experimented  upon,  three  of  which  were 
rendered  insensible,  all  died,  and  the  fourth  had  not  sufficient 
of  the  vapor  to  render  it  in  the  least  insensible ;  and  yet,  for  two 
or  three  days,  it  was  doubtful  whether  it  would  recover.  Like 
the  bromide  of  olefiant  gas  (ethylene  bromide),  its  immediate 
effects  were  not  so  dangerous,  as  the  consequences  of  inhalation 
were  in  a  few  hours ;  even  when  not  enough  to  produce  insen- 

12* 


274  ARTIFICIAL   ANiESTHESIA. 

sibility  had  been  used,  and  when  the  animal  to  all  appearances 
had  been  perfectly  well,  death  would  supervene.  In  one  case 
the  odor  of  the  ether  was  distinctly  perceptible  in  the  brain 
twelve  hours  after  death,  and  Nunnelly  thinks  that  death  was 
caused  by  blood-poisoning*  Therapeutically  it  has  been  used 
in  recent  years,  '  by  inhalation  to  bring  the  stjstem  speedily  under 
the  influence  of  iodine.'     {National  Dispensatory,  1880,  p.  114.) 

**  Bromide  of  Olefiant  Gas  or  Ethylene  Bromide 

was  also  condemned  by  Nunnelly  {loc.  cit.,  p.  327),  who  stated 
that,  although  it  produced  insensibility,  it  caused  the  respiration 
to  become  laborious,  and  although  the  appearances  of  distress 
speedily  disappeared  when  the  animals  were  released,  yet  in  a 
few  hours  they  all,  without  exception,  died.  He  further  re- 
marks that  in  this  respect  it  differs  from  other  (?)  antesthetics, 
because  of  the  animals  appearing  well  immediately  following 
the  experiments,  but  soon  dying.  He  attributes  this  effect  to 
blood-poisoning. 

*'  Iodoform 

was  not  sufficiently  volatile  to  cause  ansesthesia  (Nunnelly), 
hut,  from  what  we  know  of  its  use,  when  given  per  stomach 
or  used  locally,  it  possesses  powerful  ansesthetic  (analgesic) 
properties.  Unfortunately  it  has  not  been  used  sufficiently 
internally,  nor  have  physiological  experiments  been  pur- 
sued to  such  an  extent  as  to  give  us  an  accurate  knowl- 
edge of  its  action  on  the  economy ;  yet  we  do  know  that 
it  diminishes  the  pulse-rate,  produces  muscular  and  nervous 
debility,  and  is  decomposed  in  the  body,  and  that,  when  ap- 
plied to  mucous,  serous  or  abraded  surfaces,  it  becomes  de- 
composed by  the  fat,  and  the  iodine  is  eliminated  from  the  body 
in  the  form  of  soluble  iodides.  If  iodine  is  liberated  in  the 
system,  no  further  comment  is  needed."  (See  Iodoform  under 
Local  Antesthetics.) 

*  Quotations  on  pp.  273-280  chiefly  from  Professor  Eeichert. 


GHLORIDE   OF   ETHYDENE.  275 

Carbon  Dicliloride  or  Chloric  Ether 

has  been  used  to  a  sufficieHt  extent  to  indicate  that  it  pro- 
duces distinct  cardiac  depression. 

Bromoforin, 

which  possesses  undoubted  anaesthetic  properties,  was  found 
in  experiments  of  Dr.  Reichart,  to  powerfully  depress  the  heart, 
and  in  one  experiment  on  a  small  dog  the  intravenous  in- 
jection of  thirty  minims  of  the  preparation  caused  imme- 
diate cardiac  arrest.  Consequently,  it  was  considered  useless 
to  pursue  any  further  investigation  in  this  line. 

"Tetrachloride  of  Carhon 

(CCIJ  was  used  by  Laffont  {America,n  Dispensatory,  1880,  p. 
354),  who  found  that  it  caused  great  debility  of  the  heart,  and 
lowering  of  the  vascular  tension.  Simpson  {Medical  Gazette, 
1865,  ii.  p.  651)  previously  used  it  under  the  ndme  of  Bichloride 
of  Carbon,  or  Chlorocarbon,  and  more  recantly  the  same  com- 
pound has  been  used  by  Smith  {Lancet,  1867,  i.  pp.  575,  660). 
The  latter  observer  found,  in  the  post-mortem  examinations  of 
the  animals  experimented  on,  that  the  auricles  were  much  dis- 
tended with  blood,  and  especially  on  the  right  side.  He  no- 
ticed that  the  heart  did  not  beat  after  the  cessation  of  respira- 
tion, and  that  the  pulse  was  decidedly  lowered.  In  conclusion, 
it  is  stated  that  '  when  pushed  to  extremes,  it  seems  to  destroy 
life  by  causing  an  arrest  of  the  circulation  of  the  blood  through 
the  lungs,  a  distended  condition  of  the  right  side  of  the  heart, 
an  insufficient  supply  of  blood  to  the  left  side  of  the  heart,  and 
consequently  diminished  systemic  circulation.' 

*'  Chloride  of  Ethydene,  or  Ethylidene  or  Ethidene, 

was  first  used  by  Snow,  (Ancesthetics),  and  more  recently  by 
Liebreich  {3Ied.  Times  and  Gazette,  1870,  i.  p.  642)  ;  the  Brit- 
ish Medical  Association  Committee  ('  Action  of  Anaesthetics,' 
British  Medical  Journal,  1879);  Bird,  {Medical  Times  and  Ga- 
zette, 1879,  i.  pp.  62) ;  and  Reeve,  (New  Remedies,  Nov.  1880, 
p.  334 — quoted  from  Chicago  Med.  and  Surg.  Examiner,  June, 


276  ARTIFICIAL  ANAESTHESIA. 

]  880).  Liebreich,  considers  it  somewhat  safer  than  chloroform  ; 
the  British  Committee  found  an  enormous  diminution  in  the 
arterial  pressure,  and  that  the  heart-beats  became  so  infre- 
quent as  to  be  virtually  ineffectual  in  supplying  the  respira- 
tory centres  with  blood.  Bird  esteems  it  a  powerful  cardiac 
stimulant,  and  states  that  all  the  patients  under  its  influence 
presented  the  appearance  of  a  strong  cardiac  stimulant,  but 
that  he  would  not  like  to  keep  a  patient  long  under  its  influ- 
ence for  fear  of  a  reaction  in  the  opposite  direction.  His  in- 
vestigations were  not  carried  far  enough  to  justify  this  conclu- 
sion of  its  cardiac  action,  and,  as  his  conjecture  is  contrary  to 
the  results  of  all  other  investigators,  it  must  be  rejected  as  un- 
tenable. Reeve  found  a  diminution  of  blood  pressure,  which 
differed  from  that  caused  by  chloroform,  because  it  did  not  ad- 
vance to  complete  extinction,  nor  exhibit  such  wide  variations 
in  its  effects  at  different  times  in  the  same  animal.  A  death 
from  its  use  in  Berlin  has  been  reported  by  Kappeler  {loc.  cit.). 
Steffer  (Binz's  'Evidence  of  Therapeutics,' p.  69)  says  that  it  re- 
sembles chloroform  in  ultimate  action,  yet  is  not  so  dangerous. 

**  Ethylene  or  Ethene  Bicliloride,  or  Diitcli  Liiquid, 

was  used  by  Nunnelly  [loc.  cit.),  who  speaks  of  it  in  a  decid- 
edly laudable  way,  stating  that  just  as  small  a  quantity  will 
produce  anaesthesia  as  chloroform,  but  that  a  much  larger 
quantity  is  required  to  destroy  life.  Simpson  {Edinburgh 
Medical  Journal,  1848,  vol.  viii.  p.  740)  also  made  some  investi- 
gations with  it,  and  found  that  vi'hen  its  vapor  was  inhaled,  it 
caused  so  much  irritation  in  the  throat  that  but  ievf  persons 
could  endure  inhaling  it  until  anaesthesia  was  produced,  and 
that  the  condition  of  anaesthesia  was  not  attended  with  any 
excitement  of  the  pulse.  On  himself  it  produced  such  a  de- 
gree of  irritation  in  the  throat  that  it  did  not  disappear  for 
many  hours.  Recently,  the  British  Committee  [loc.  cit.)  used 
it,  and  report  that  no  anaesthesia  was  produced  up  to  the 
commencement  of  convulsions.  The  results  of  a  series  of  ex- 
periments (Phila.  Med.  Times,  May  7,  1881)  made  by  Reichert 
with  this  compound  indicate  that  it  is  a  powerful  anaesthetic, 
and  that  it  fulfils  considerable  that  Nunnelly  claimed  for  it. 


ETHYLENE   BICHLORIDE.  277 

It  is  undoubtedly  a  direct  cardiac  depressant.  Why  the  Brit- 
ish Committee  got  such  anomalous  results  is  rather  curious." 

Butyl  Chloride 

(British  Committee)  caused  the  cardiac  pulsation  to  become 
weaker,  and  finally  extinguished ;  while  Methyl  Chloride  only 
effected  drowsiness.  Isobutyl  Chloride  was  not  noticed  as  re- 
garding any  cardiac  action. 

Bichloride  of  Ethylene  (C^H^ChJ. 
(dutch  liquid.) 

Bichloride  of  ethylene  is  a  colorless,  oily  liquid,  having  an 
ethereal  odor  resembling  that  of  chloroform  and  a  sweetish 
taste;  specific  gravity  1.270,  boils  at  185°  F, ;  sparingly  soluble 
in  water,  and  freely  soluble  in  alcohol  and  ether ;  it  is  inflam- 
mable, and  burns  with  a  yellow  flame  with  a  green  border. 
This  agent,  when  tested  by  Prof.  Simpson,  was  found  so  irri- 
tating to  the  throat  that  it  could  not  be  used  long  enough  to 
induce  the  anaesthetic  state.  By  the  action  of  chlorine  upon 
Dutch  liquid  a  number  of  chlorinated  compounds  may  be  ob- 
tained, which  are  isomeric  with  chlorinated  compounds.  Nu- 
merous careful  experiments  with  ethylene  bichloride  were 
made  by  Professor  Reichert,  of  the  University  of  Pennsylvania 
(see  pamphlet  "Ethylene  Bichloride  as  an  Anaesthetic 
Agent,"  Phila.  Med.  Times,  May  21  and  June  4,  1887). 

Early  in  his  experiments  he  learned  that  "  in  order  to  know 
whether  an  animal  was  completely  anaesthetized,  it  was  not 
necessary  to  consult  the  conjunctiva,  but  merely  to  watch  the 
respirations,  for  just  so  soon  as  they  became  very  frequent  the 
animal  was  either  ancesthelized  or  so  near  and  rapidly  approach- 
ing that  condition  that  the  inhaler  could  be  removed  and  the  opera- 
tion proceeded  with.  If  after  the  second  stage  is  very  pro- 
nounced the  administration  of  the  ethylene  be  continued,  the 
animal  invariably  dies  from  a  failure  of  the  respiration,  and  never 
in  a  single  instance  could  he  induce  death  by  a  stoppage  of  the 
heart  by  the  inhalation  of  the  vapor,  no  matter  how  concentrated 
the  vapor  was. 


278  AETIFICIAL   ANiESTHESIA. 

"The  dose  required  to  produce  ansesthesia  was  about  the 
same  as  chloroform,  for  the  difference  was  so  slight  as  to  be  un- 
noticeable. 

"  The  diverse  and  interesting  results  of  these  parallel  experi- 
ments with  chloroform  are  so  valuable  as  scarcely  to  be  over- 
estimated ia  a  comparison  of  the  relative  safety  of  the  two 
compounds,  as  the  pulse  in  the  ethylene  experiment  could  be 
detected  on  the  tracing  for  over  twenty-five  minutes,  notwith- 
standing that  the  animal  was  continuously  inhaling  the  vapor 
during  the  whole  of  this  time,  while  in  the  chloroform  experi- 
ment but  a  single  dose  was  placed  on  the  inhaler,  the  pulse- 
curves  rapidly  diminished  in  size,  and  the  pressure  fell  to 
twelve  millimetres  in  a  little  over  two  minutes,  and  the  puLse 
was  extinct. 

"It  needs  no  further  argument  to  prove  that  this  article  (or, 
probably,  ethydene  chloride)  should  replace  chloroform  in 
such  cases  where  ether  cannot  be  used ;  but,  as  it  is  inflamma- 
ble, care  must  be  exercised  in  its  usr  at  night,  and,  as  it  is  a 
cardiac  and  respiratory  depressant  (in  toxic  amounts),  the 
same  cautions  should  be  observed  in  its  use,  and  never  should 
it  be  employed,  if  possible,  without  amyl  nitrite  at  hand." 

Ethylene  Ethylate  and  Ethylene  Methylethylate 

were  experimented  with,  and,  although  each  of  them  pos- 
sessed some  slight  anaesthetic  powers,  they  were  so  feeble  in 
this  respect  and  caused  such  distress  in  breathing  that  they 
were  abandoned  as  useless. 

"Ethyl  Nitrate 

was  used  by  Simpson,  who  found  it  easy  and  pleasant  to  inhale, 
and  to  possess  very  rapid  and  powerful  antesthetic  properties, 
and  that  small  quantities,  such  as  fifty  or  sixty  drops,  sprinkled 
on  a  handkerchief,  produced  insensibility  after  a  few  inspira- 
tions. Shortly  after,  Nunnelly  stated  that  it  possessed  not 
much,  if  any,  anaesthetic  power  ;  and  my  own  experiments  con- 
firm this,  as  the  following  result  will  show : 

*' Rabbit— Time,  12.32.  Added  one  drachm  to  inhaler;  ,32J, 
struggles ;  .33,  breathing  deeper  and  slightly  faster ;  .34,  no  change ; 


AMYLENE.  279 

,35,  added  a  second  drachm  to  inhaler  ;  .35^,  respirations  again 
temporarily  increased;  .37^,  orbital  refluxes  slightly  diminished  (")  • 
.39,  added  a  third  drachm  to  inhaler ;  .40,  respirations  increased  ; 
.43,  animal  not  anaesthetized,  but  somewhat  drowsy,  and,  although 
the  inhalation  was  continued  for  several  minutes,  no  anaesthesia  was 
produced." 

lotUde  of  Methyl  (CH3T). 

This  compound  was  discovered  by  Dumas  and  Peligot  in 
1835,  and  is  made  by  combining  phosphorus,  iodine  and  methy- 
lic  alcohol.  A  safer  and  more  agreeable  preparation  of  it  is 
made,  according  to  Wanklyn,  by  mixing  iodide  of  potassium 
and  anhydrous  metbylic  alcohol  in  a  retort,  in  equivalent  pro- 
portions ;  dry  chlorine  gas  is  passed  into  the  mixture,  which, 
is  then  distilled,  and  the  distillate  agitated  with  water  and 
rectified. 

Iodide  of  methyl  is  a  colorless  liquid  of  an  ethereal  odor. 
Specific  gravity,  2.199,  at  32=  F. ;  it  boils  at  110°  F.,  and  burns 
with  difliculty,  giving  off  violet  vapors.  This  agent  was  pro- 
posed in  1868  by  Dr.  B.  W.  Richardson  as  an  anaesthetic,  but 
was  found  by  him  and  by  Prof.  Simpson  as  unsafe.  It  has 
been  recommended  as  a  local  anaesthetic  in  cancerous  cases. 

Ainylene. 

The  vapor  of  this  liquid  was  introduced  by  the  late  Dr. 
Snow  as  a  substitute  for  the  vapor  of  chloroform.  It  produces 
a  loss  of  sensibility  without  causing  complete  coma  or  stupor. 
Its  use  has  already  led  to  at  least  two  deaths,  and  is,  according 
to  Dr.  Taylor,*  not  so  safe  an  agent  as  chloroform  vapor  for 
surgical  purposes.  The  only  appearance  met  with  in  one  fatal 
case  was  an  emphysematous  state  of  the  lungs,  or  excessive 
dilatation  of  the  air-cells  [Medical  Times  and  Gazelle,  At^xW  4th 
and  18th,  1857,  pp.  332,  381),  and  in  the  other  a  distension  of 
the  right  cavities  of  the  heart  with  dark  fluid  blood.  There  was 
no  congestion  of  the  brain,  and  no  smell  of  amylene  percepti- 
ble in  the  body. — Medical  Times  and  Gazette,  August  8th,  1857, 
p.  133. 

*  On  Poisons,  op.  cit.  p.  627. 


280  ARTIFICIAL  ANESTHESIA. 


**  Chloral  Hydrate, 

Although  not  an  antesthetic  in  a  therapeutic  sense,  has,  like 
chloroform  and  ethyl  bromide,  given  us  painful  instances  of 
its  acting  at  times  altogether  out  of  proportion  to  the  dose. 
Fuller  {Lancet,  March,  1871),  quotes  a  case,  where  thirty- 
grains  caused  death  in  a  young  lady.  Schwaighofer,  {Iriah 
Hospital  Gaz.,  1873)  reports  another,  of  a  drunkard,  in  which 
a  drachm  produced  death;  and  three  other  cases  (Reynolds, 
Practitioner,  March,  1870 ;  Watam,  Med.  and  Surgical  Repor- 
ter, January,  1871 ;  Fuller,  loc.  Qit.),  in  which  forty-five, 
eighty,  and  thirty  grains,  respectively,  caused  alarming  symp- 
toms, and,  from  the  large  dose,  death  nearly  ensued.  Death 
has  resulted  from  a  dose  of  ten  grains  [American  Dispen- 
satorij,  1880,  p.  396).  Other  deaths  have  been  reported 
{Medical  Times  and  Gaz.,  1871,  pp.  1831,  672;  Norris,  Lancet, 
1871,  i.  p.  226,  and  Browne,  ibid.  p.  674) ;  and  in  some  of  these 
cases  indisputable  evidences  of  its  power  of  weakening  the 
heart  were  present.  Did  chloral  hydrate  become  decomposed 
in  the  system  into  formic  acid  and  chloroform  (Person ne,JbMr/i. 
de  Pkarm.  et  Ckimie,  1870;  and  Pellogio,  Schmidt's  Jahrbiicher, 
bd.  cli.  p.  89 ;  Liebreich,  Wie?ier  Med.  Wochensch.,  Aug.,  1860), 
we  could  readily  account  for  its  acting  at  times  in  a  manner 
wholly  disproportionate  to  the  dose,  and  for  its  being  a  cardiac 
depressant ;  but,  as  recent  investigations  disprove  this  theory 
(Hammertin,  Schmidt's  Jahrbiicher,  bd.  cii.;  Rajursky,  Ibid., 
bd.  cli.;  Arnory,  N.  Y.  Med,  Jour.,  1870;  Djurburg,  Schmidt's 
Jahr.,  bd.  cli. ;  Leurison,  Archiv.  Anat.  u.  Phys.,  1870),  we  must 
look  elsewhere  for  this  toxic  principle." 

Replies  received  from  Dr.  B.  W.  Richardson,  who  in- 
troduced Methylene, — They  deal  with  points  of  import- 
ance to  the  general  practitioner,  working  short-handed,  as  is 
usually  the  case. 

1.  "Methylene  can  be  given  from  any  simple  inhaler;  but, 
as  it  evaporates  more  quickly  than  chloroform,  it  must  be  con- 
fined by  some  structure  that  will  fold  into  a  funnel,  like  strong 
paper,  a  piece  of  starched  linen,  or  a  fold  of  leather." 

2.  "  It  will  keep  as  long  as  chloroform  in  a  cool  place  and 


METHYLENE  CHLORIDE  AS  AN  ANAESTHETIC.     281 

away  from  the  light.    I  narcotized  quite  recently  from  a  speci- 
men which  had  been  in  keeping  many  months.'" 

Ethylei^e  Chloride  (C2H4Ch2)  hasbeen  found  to  possess 
the  singular  and  unpleasant  property  of  causing  opacity  of  the 
cornea.  The  effect  was  observed  not  long  since  on  dogs  ex- 
perimented  upon  by  Drs.  Raphael  Dubois,  and  L.  Eoux,  of 
Lyons.  At  the  same  time  it  was  noticed  the  opacity  takes 
place  no  matter  how  the  chloride  has  been  administered. 
Further  experiments  with  a  view  to  determine  the  cause  of 
the  phenomenon  have  proved  that  the  accident  is  due  to  the 
direct  action  of  the  chemical  through  the  aqueous  humor,  hav- 
ing for  effect  to  dehydrate  the  cornea,  and  thus  deform  and 
harden  it. — Paris  Letter,  Therapeutic  Gazette,  Oct.  15,  1888, 
p.  709. 

Methylene  Cliloride  as  an  Ansestlietic. 

In  a  recent  article  on  this  drug  by  Dr.  Eicbholz,  and  Profes- 
sor Genther  {Deutsche  Medizinal  Ztitung,  August  22,  1887,  and 
Therapeutic  Gazette,  Dec.  15, 1887),  the  authors  claim,  that  until 
now  the  pure  article  has  never  been  tested  as  an  anaesthetic 
on  man.  This  is  a  mistake,  as  we  had  the  article  chemically 
pure,  prepared  by  Dr.  Greene,  of  this  city,  and  made  numer- 
ous tests  on  animals  and  man,  and  our  experiments  coincided 
with  theirs,  that  it  was  in  its  action  like  chloroform,  the  only  ad- 
vantage being  that  methylene  chloride  is  less  dangerous  in  its 
action  on  the  heart. 

They  recommend  a  mixture  of  methyl  alcohol  with  chloro- 
form, a  mixture  which  we  consider  more  dangerous  than 
chloroform  pure,  as  it  is  apt  to  be  all  alcohol  first  and  almost 
pure  chloroform  at  the  last. 

They  conclude  their  paper  with  the  following  sentences: 
First,  that  the  substance  heretofore  employed  as  methylene 
chloride  is  a  mixture  of  chloroform  and  methyl  alcohol  (this 
is  not  new,  as  we  published  the  same  fact  in  our  second  edition, 
also  in  1887,  in  Med.  and  Surg.  Reporter,  of  this  city) ;  second, 
this  mixture  is  to  be  preferred  to  chloroform  for  the  produc- 
tion of  narcosis  (this  is  not  good  or  safe  advice,  for  the  reasons 
before  stated) ;  third,  that  pure  methylene  chloride  produces 


282  ARTIFICIAL  ANAESTHESIA. 

narcosis  quite  as  rapidly  and  as  profound  as  either  of  the 
above  preparations ;  fourth,  that  the  action  of  pure  methylene 
chloride  on  the  circulation  and  respiration  is  by  far  less  dan- 
gerous thau  that  of  either  of  the  other  preparations  (the  dis- 
advantages of  this  preparation  ape,  first,  tliat  it  produces  sali- 
vation ;  chloroform,  pure,  does  not ;  narrowing  of  the  pupil,, 
which  chloroform  does  not ;  rigidity  of  muscles  of  the  neck, 
which  chloroform  does  not). 

M.  Polaillon,  recently  read  a  memoir  before  the  French  Acade- 
my of  Medicine  {La  Pratique  Medicale,  July  2,  1889),  in  which 
he  communicated  the  results  of  his  experiments  with  methylic 
chloroform  (four  volumes  of  chloroform  containing  one  volume 
of  methylic  alcohol).  He  was  led  to  the  employment  of  this 
antesthetic  through  the  fiital  results  which  recently  followed  at 
his  hands  the  employment  of  chloroform  as  an  anaesthetic ;  and 
he  has  now  employed  this  methylic  chloroform  in  seventeen 
different  instances  in  women.  In  two  of  these  the  anaesthesia 
was  incomplete,  while  in  fifteen  others  the  sleep  was  very  satis- 
factory, and  might  have  been  readily  prolonged  indefinitely 
without  inconvenience.  Vomiting  occurred  three  times  after 
wakening,  once  during  the  narcosis,  and  in  this  case  the  vomit- 
ing produced  prolapse  of  die  intestine  after  a  laparotomy.  He 
believes,  however,  that  the  sleep  produced  by  me  hylic  chloro- 
form has  advantages  over  that  due  to  ordinary  chloroform, — 
the  awakening  is  much  more  easy,  and  the  discomfort  much 
less.  He  contends,  therefore,  that  it  might  be  substituted  with 
advantage  for  ordinary  chloroform.  Polaillon  has  likewise  em- 
ployed this  agent  in  ten  operations  on  the  male  subject;  in  four 
cases  it  was  not  possible  to  narcotize  the  patient,  although  the 
attempt  was  persisted  in  for  more  than  half  an  hour.  In  one 
case,  at  the  end  of  seventeen  minutes,  there  was  only  reduction 
of  sensibility  without  anresthesia.  In  another  case,  twenty- 
three  minutes  after  the  commencement  of  administering  the 
anaesthetic,  symptoms  of  asphyxia  were  noted,  and  necessitated 
the  performance  of  tracheotomy.  In  four  cases  the  anaesthesia 
was  complete,  once  in  ten  minutes,  one  between  ten  and  fifteen 
minutes. 

Ethidene  Dichloride   (C^H^Clj)   is    isomeric  with    the 


ETHIDENE   DICHLOEIDE.  283 

ethylene  bichloride.  In  the  journal  of  the  British  Medical 
Journal  will  be  found  the  reports  of  their  committee  appointed 
to  investigate  the  action  of  anse  sthetics.  The  latest  was  that 
of  December  18,  1880.  In  conducting  these  investigations  two 
lines  were  followed :  first,  to  discover  wherein  the  special  dan- 
gers of  chloroform  consist;  and  second,  to  attempt  to  find  some 
safer  anaesthetic. 

Of  a  considerable  number  of  substances  which  were  made 
trial  of  in  the  course  of  this  inquiry,  ethidene  dichloride  ap- 
peared to  yield  the  most  promising  results ;  and,  consequently, 
the  actions  of  this  compound  were  submitted  to  more  special 
investigation.  So  long  ago  as  the  year  1848,  attention  was 
directed  to  ethidene  dichloride  by  Drs.  Simpson  and  Snow, 
who  had  employed  it  in  several  cases ;  and  since  then  it  has 
been  made  use  of  by  Nunnelly,  Liebreich,  Langenbeck  and 
various  other  observers.  The  committee  were  fortunate 
enough  to  be  able  to  make  trial  of  ausesthetics  in  the  wards  of 
the  Western  Infirmary,  Glasgow ;  and  they  were  thus  enabled 
to  compare  the  action  of  ethidene  and  chloroform  on  the 
human  subject.  They  give  details  of  fifty  unselected  cases  in 
which  each  drug  was  administered  to  produce  anaesthesia  dur- 
ing some  surgical  operation.  From  the  tabular  statements  so 
obtained  we  may  extract  some  important  facts.  The  average 
dose  of  ethidene  was  1.8  cubic  centimetres  for  each  minute  dur- 
ing which  the  patient  was  under  the  influence  of  the  anass- 
thetic ;  while,  in  the  case  of  chloroform,  the  dose  was  some- 
what smaller,  the  corresponding  figure  being  1.7  cubic  cetiti- 
metres.  The  time  required  to  anaesthetize  with  chloroform  was 
1.1  minute  greater  than  that  necessary  in  the  case  of  ethidene ; 
and  sickness  appears  to  have  been  more  prominent  during  the 
administration  of  chloroform  than  during  that  of  the  other 
anaesthetic.  The  most  important  difference  in  the  action  of 
the  two  anaesthetics,  as  observed  at  the  bedside,  consists  in 
their  influence  on  the  pulse-respiration  ratio.  Charts  are  ap- 
pended to  the  report  which  represent  this  in  graphic  form.  In 
only  one  case  did  the  pulse  fall  to  64  per  minute  during  the 
administration  of  ethidene;  and-,  in  a  large  number  of  in- 
stances, the  pulse  and  respirations  were  peculiarly  regular. 


284  ARTIFICIAL   ANAESTHESIA. 

The  report  before  us  adda  to  this  the  effect  of  ethidene  on  the 
blood-pressure,  and  shows  that  this  substance  stands  in  an 
intermediate  position  between  the  other  two  anjB'jthetics ; 
causing  more  lowering  of  pressure  than  ether,  but  less  than 
that  produced  by  chloroform. 

The  results  of  numerous  trials  of  this  agent  have  not  carried 
out  the  original  favorable  opinion  of  the  JJritish  Committee. 
It  has  been  found  to  cause  decided  lowering  of  the  respiration, 
with  severe  attacks  of  asphyxia  and  other  alarming  symptoms. 
With  fceveral  cases  death  has  followed  its  use. 

Aldehyde   (C^H^O)— Etbaldehyde,   Acetic  or  Etliylic 
Aldeliyde. 

Specific  gravity,  0.801  (32°  F.) ;  boiling  point,  22'^  C.  (71.6°  F.)  ; 
vapor  density,  1.532. 

Acetic  aldehyde  is  a  very  volatile  liquid,  produced  by  the 
oxidation  and  destructive  distillation  of  alcohol  and  other 
organic  compounds.  It  is  a  transparent,  colorless  liquid,  re- 
sembling the  ethers,  having  a  pungent,  suffocating  odor.  It  is 
very  inflammable,  and  burns  with  a  beautiful  blue  flame.  It  is 
mixed  with  water,  and  dissolves  in  alcohol  and  ether.  It  dis- 
solves sulphur  and  phosphorus,  also  iodine,  forming  a  brown 
solution  and  becomes  chemically  changed  by  the  contact  or 
addition  of  an  oxidizing  agent  which  will  reduce  it  to  acetic 
acid.  Aldehyde  possesses  antesthetic  power ;  small  quantities 
of  the  vapor  retard  the  pulse,  large  quantities  accelerate  the 
pulse  and  respiratory  movements,  while  larger  doses  arrest 
them,  causing  irritation  of  the  glottis  and  constriction  of  the 
chest,  while  the  action  of  the  heart  is  disturbed,  with  a  ten- 
dency to  entire  arrest  of  respiration.  It  has  therefore  been 
classed  as  a  dangerous  ansesthetic.  Three  to  five  cubic  centi- 
metres (thirty-six  to  sixty  grains)  injected  in  watery  mixture 
into  the  veins  of  a  medium-sized  dog,  produce  almost  imme- 
diate insensibility  and  arrest  of  respiration.  Death  is  pre- 
ceded by  dilatation  of  the  pupils. 

Every  alcohol  can  become  an  aldehyde  by  oxidation.  The 
one  referred  to  differs  only  in  the  following  point :  first,  by  the 
prefix  par  multiplying  the  chemical  equivalent  by  four — CjjHjjOs. 


ALDEHYDE.  285 

Again,  at  the  freezing-point  it  is,  like  oleic  acid,  a  solid.  In  its 
physical  properties  it  is  precisely  the  same  as  the  one  referred  to. 
It  id  also,  according  to  our  experiments,  an  ansesthetic — forty- 
five  minims,  being  inhaled  on  a  towel,  produced  a  choking,  dis- 
agreeable sensation  with  fulness  of  the  head,  but  slight  ansesthetic 
effect,  and  instead  of  accelerating  the  pulse,  it  reduces  it  from 
96  to  80.  A  second  experiment  was  made  with  sixty  minims, 
when  there  was  considerable  irritation  of  the  nose  and  throat  of 
a  peppery  character  and  no  full  anaesthesia,  but  the  pulse  rose  to 
114.  The  respiration  was  but  slightly  accelerated,  and  on  recov- 
ery, which  was  rapid,  there  was  no  severe  headache  and  no  sick 
stomach  or  vomiting;  there  was,  however,  considerable  irrita- 
tion of  the  conjunctiva  and  slight  dilatation  of  the  pupil.  The 
writer  has  tried  it  on  himself  and  other  patients,  but  with  one 
exception  it  has  been  unsatisfactory.  In  a  case  of  neuralgia  of 
the  fifth  pair,  cause  exposure,  it  was  given  in  forty-five  minim 
doses  and  the  patient  was  relieved  and  slept  all  night,  and  did 
not  find  the  taste  so  disagreeable  when  mixed  with  a  wine- 
glass of  sugar  and  water.  A  case  of  valvular  lesion  of  the 
heart,  the  patient  not  being  able  to  sleep  unless  under  the 
influence  of  i  of  a  grain  of  morphia  suppos.  and  x|^  of  atropia, 
slept  only  two  hours  from  30  minims  of  paraldehyde-  A  second 
larger  dose,  45  minims,  had  no  better  result  in  spite  of  the  fol- 
lowing mixture : 

Paraldehydi ttLxxx. 

Aquse ad^jss. 

Syrupi  aurantii ^  ii. 

Spts.  chloroformi tlXxxx. 

M,  ft.  haustus.     Hora  somni  suraeod. 


286  ARTIFICIAL  ANJ3STHESIA. 


CHAPTEE    XVII. 

Etherization  by  the  Rectum. 

Like  all  discoveries  in  science  and  in  the  medical  arts,  there 
has  to  be  a  beginning  and  a  gradual  advance  in  observation 
and  experiment.  It  is  stated  that*  the  first  suggestion  of  the 
possibility  of  anrestbesia  by  the  rectum  in  the  human  being 
was  by  M.  Roux,t  of  Paris,  in  1847;  but  it  was  a  mere  idea 
that  such  a  condition  as  insensibility  could  be  produced  by  the 
administering  of  ether  per  rectum. 

This  was  followed  by  experiments  of  Dr.  Vincenti  y  Nedo,t 
who  injected  ether  into  the  lower  bowel  of  rabbits  and  produced 
ansesthesia,  followed  by  inflammation,  and  in  some  instances 
the  death  of  the  animal. 

The  next  year  (1848)  M.  Mara  Depuy,  of  Paris,  produced 
the  same  injurious  results,  even  when  the  ether  was  diluted 
with  water. 

In  1847,  Professor  PirogoflF,  of  Russia,?  to  whom  the  credit 
is  due  of  first  inducing  insensibility  in  the  human  being  by 
means  of  the  vapor  of  ether  per  rectum,  began  his  experiments 
by  injecting  the  vapor  of  ether,  and  ether  itself  largely  diluted 
with  water,  for  the  relief  of  neuralgia,  spasm  of  the  muscles 
of  deglutition,  lead  colic,  inflammatory  pains  of  the  joints,  and 
cancer  of  the  intestinal  canal,  and  reported  favorably  of  its 
anodyne  and  antispasmodic  effects.  He  subsequently  recom- 
mended an  apparatus  for  the  use  of  the  vapor,  which  was  em- 
ployed by  other  surgeons  in  Europe. 

*  Virginia  Medical  Monlhlij,  Richmond,  October,  1884,  p.  3C1. 

t  Compt.  Rendu,  de  TAcademie  des  Sciences,  February  1,  1847. 

X  Gazette  Medicale  de  Paris,  1847. 

g  Recherchea  pratiques  et  phj'^siologiques  sur  1'  etherization,  St.  Petersburg,  1847. 


ETHEE   BY   THE   EECTUM.  287 


Advantages  of  Ether  by  the  Rectum. 

The  advantages  of  ether  by  the  rectum  are  as  follows:  It 
avoids  the  first  and  chief  danger  to  the  respiration,  the  produc- 
tion of  stertor,  and  the  falling  back  of  the  jaw  and  tongue. 
Second  danger  :  It  avoids  the  irritating  influence  of  ether  upon 
the  mucous  membrane  of  the  throat  and  air-passages — first 
shown  by  croupy  respiration  and  flow  of  a  frothy  mucus.  Third  : 
It  prevents  a  dangerous  complication — tetanic  setting  of  the 
inspiratory  muscles  of  the  chest;  no  air  enters ;  respiration  with 
the  diaphragm  fails  to  fill  the  lungs,  and  the  patient  dies  as  in 
true  tetanus.  Fourth:  It  prevents  simple  exhaustion,  another 
source  of  danger,  as  the  patient  can  take  nourishment  before 
the  operation,  to  sustain  the  system.  Death  is  not  so  apt  to 
occur  from  slowly- failing  respiration  when  the  ether  is  em- 
ployed by  the  rectum.  Fifth :  It  avoids  the  distressing  and 
exhausting  vomiting  and  lasting  nausea  which  is  so  disastrous 
in  abdominal  section,  in  operations  for  hernia,  and  sections  of 
the  cornea  and  iris. 

The  following  is  one  of  the  most  recent  reports  of  the  ad- 
ministration of  ether  per  rectum,  which  we  are  able  to  collect, 
(British  Med.  Jour.,  August,  1888),  and  the  cases  were  under  the 
care  of  F.  H,  Appleby,  of  Newark,  England; 

"Administration  of  Ether  per  Rectum. — I  have  this 
day,  for  the  fourth  time,  administered  ether  joer  rectum,  and  send 
you  the  following  short  notes  of  the  case,  which  may  possibly 
be  of  interest  to  your  readers : 

The  patient  was  a  woman,  aged  29,  who  has  had  four 
children  ;  a  total  abstainer,  and  in  fair  health.  She  required 
the  extraction  of  the  whole  of  the  teeth  in  the  upper  jaw, 
twelve  in  number;  some  were  badly  decayed,  others  were 
stumps.  Mr.  R.  F.  H.  King,  was  the  operator,  and  the  opera- 
tion was  performed  in  his  operating-room.  The  ether  was 
administered  through  a  simple  apparatus  made  for  me  by 
Messrs.  Maw,  Son,  and  Thompson  ;  the  ether  used  was  of  the 
specific  gravity  of  0.717,  and  its  boiling  point  74°  F.  Precisely 
two  minutes  after  the  commencement  of  administration  the 
characteristic  smell  was  detected  in  the  patient's  breath;    at 


288  ARTIFICIAL   ANAESTHESIA. 

the  same  time  she  remarked,  'Oh,  I  can  taste  it.'  In  7  min- 
utes 66  seconds,  she  was  sufficiently  under  its  influence  lor  Mr. 
King  to  commence,  and  the  administration  was  continued  until 
eight  of  the  teeth  had  been  extracted ;  then,  exactly  ten  min- 
utes from  its  commencement,  it  was  discontinued,  and  the 
remaining  four  teeth  were  extracted  without  any  sensation  of 
pain.  The  whole  operation  lasted  exactly  fifteen  minutes.  The 
teeth  were  very  awkward  to  extract,  and  could  not  be  taken 
out  hurriedly,  as  they  were  very  brittle,  and  required  great 
care.  The  amount  of  ether  used  was  fourteen  drachms  ;  and 
the  sole  discomfort  complained  of  by  the  patient  was  a  sense 
of  heat  in  the  rectum.  The  pulse  was  quickened  very  con- 
siderably, going  up  from  80  to  132,  and  being  full  and  bound- 
ing; after  the  expiration  of  eight  minutes  it  slowed  down  to 
108,  and  became  soft;  it  was  always  regular.  The  respiration 
was  not  interfered  with  in  the  least,  and  we  could  not  tell  that 
it  varied  at  all.  There  was  no  sickness,  and  twenty-one  min- 
utes from  the  commencement  the  patient  rose  and  walked 
with  assistance  into  another  room.  She  was  exhilarated,  and 
remarked  that  she  felt  rather  stupid,  but  had  not  felt  the 
extractions.  Of  course,  the  anaesthesia  was  not  pushed  to  a 
sufficient  extent  to  produce  insensibility  to  the  pain  of  a  more 
severe  operation  ;  but  in  my  three  previous  cases,  which  were 
all  for  cancer  of  the  tongue  and  floor  of  the  mouth,  in  two 
complete  anaesthesia  was  produced  in  twenty  minutes,  in  the 
third,  a  strong  burly  man,  who  had  been  rather  a  free  liver, 
the  result  was  a  failure,  and  it  had  to  be  administered  in  the 
usual  way." 

For  prolonged  dental  operations  we  feel  sure  it  will  be  very 
useful,  as  it  gives  the  operator  more  command  over  his  patient; 
there  is  no  inhaler  in  his  way,  and  he  can  take  his  time, 
knowing  that  the  patient  can  be  kept  under  its  influence. 

The    Chief    Dang-er   from    the   Administration   of 
Ether  per  Rectum. 

The  chief  danger  from  the  administration  of  ether  per 
rectum  has  been  found,  as  has  been  shown  in  the  report  of  the 
cases  given — first,  the  over-distension  of  the  bowels  with  the 


ETHER   BY   THE   RECTUM.  289 

ether  vapor,  or  the  tenesmus  with  bloody  discharges  from  the 
rectum  caused  by  fluid  ether  being  forced  through  the  tube 
and  deposited  in  contact  with  the  mucous  membrane,  pro- 
ducing freezing  of  the  parts  and  secondary  inflammation  and 
ulceration.  Experiments  have  demonstrated  that  the  cool 
rubber  tubing  which  has  been  employed,  had  a  tendency, 
unless  kept  warm  by  wrapping  with  cotton  or  felt,  to  produce 
a  rapid  condensation  of  the  vapor  driven  over  into  ether, 
which  boils  by  the  simple  heat  of  the  hand,  or  93°  or  96°  F. 
The  temperature  of  the  water-bath  should  not  exceed  103°  or 
105°  F.  If  the  temperature  is  allowed  to  rise  to  120°  or  130°  F, 
the  boiling  becomes  so  active  as  to  drive  over  fluid  ether. 

In  a  few  rare  operations,  the  vapor  of  ether  per  rectum  may 
be  employed  wilh  advantage,  as  in  cases  of  excision  of  the 
superior  maxilla  [Medical  News,  Januaiy  10, 1885).  Dr.  George 
A.  Peters,  of  New  York,  found  that  the  administration  of  the 
ether  by  the  rectum  in  two  operations  on  the  superior  max- 
illa, performed  upon  a  single  patient,  was  eminently  satisfac- 
tory. The  patient  was  profoundly  anaesthetized,  and  the  an- 
aesthesia continued  for  some  time;  but  he  came  out  from  under 
the  influence  of  ether  with  less  subsequent  annoyance  than 
usually  follows  the  administration  of  this  anaesthetic.  Dr.  L. 
A.  Stimson  devised  an  instrument  for  this  operation,  consist- 
ing of  a  tube  about  the  size  of  a  No.  40  urethral  catheter,  sur- 
rounded at  one  end  with  a  large  sponge  with  a  rubber  coating, 
which,  when  passed  into  the  pharynx,  prevents  the  flow  of 
blood  in  that  direction  while  the  patient  breathes  through  the 
tube. 

In  an  addition  or  appendix  to  the  second  edition  of  our 
"Manual  of  Anaesthetics,"  we  entered  more  into  details,  and 
presented  all  the  cases  and  facts  up  to  that  time  on  the  Use  of 
Ether  per  Rectum ;  in  this  we  have  summarized  the  facts  in  the 
briefest  manner,  and  yet  given  all  the  essential  details,  with 
new  cases. 

Administratiou  of  Ether  per  Rectum. 

In  the  method  of  etherization  per  rectum,  the  most  obvious 
advantages  are  as  follows : 
13 


290  ARTIFICIAL  ANAESTHESIA. 

1.  Dyspnoea  is  avoided,  and  the  patient  is  saved  from  the 
anxiety  due  to  a  sense  of  impending  suffocation. 

2.  There  is  avoided  the  danger  of  simultaneous  irritation  of 
the  superior  laryngeal  and  pneumogastric  nerves  at  the  pe- 
riphery— these  irritations  neutralizing  each  other  in  the  respi- 
ratory centre,  and  suspending  respiration  entirely. 

3.  The  danger  of  asphyxia  is  lessened,  the  patient  not  being 
drowned  in  his  own  mucus,  and  the  integrity  of  the  pulmonary 
mucous  membrane,  as  an  organ  of  gas  exchange,  is  preserved. 
Of  course,  some  vapor  finds  its  way  into  the  lungs,  and  acts  there 
as  a  local  irritant,  elimination  being  by  that  channel.  But 
the  quantity  is  not  great,  and  does  not  constitute  a  source  of 
danger.  In  the  cases  reported,  the  increase  in  secretion  was 
too  trifling  for  discovery. 

4.  The  stage  of  excitation  is  therefore  not  prolonged  by  the 
struggles  for  breath.  In  general,  it  may  be  said  that  the  de- 
lirium of  any  alcoholic  intoxication  is  a  pleasant  and  good- 
natured  one,  unless  the  patient  is  crossed,  as  he  certainly  feels 
himself  to  be  when  a  wet  towel  is  pressed  over  his  face. 

5.  Nourishment  may  be  taken  before  operation  to  sustain 
the  powers  of  life  and  lessen  the  dangers  from  shock. 

6.  Return  to  consciousness  is  prompt,  this  stage  not  being 
prolonged  by  carbonic  acid  poisoning. 

7.  The  anresthetic  seems  as  readily  suspended  as  by  the 
o  'dinary  method,  the  bowel  being  promptly  emptied  by  gentle 
massage. 

8.  Economy  in  ether  is  an  advantage  hardly  to  be  men- 
tioned with  more  important  considerations. 

The  more  obvious  disadvantages  are  : 

1.  The  exposure  of  person  required,  the  abdomen  being 
necessarily  under  observation,  even  if  the  catheter  be  inserted 
under  cover. 

2.  More  judgment  and  experience  are  required  in  the  ad- 
ministration than  by  the  ordinary  method,  overboiling  in  the 
apparatus  and  too  much  distension  being  both  painful  and 
highly  dangerous.  The  warning  to  cease  is  sudden,  and  must 
be  immediately  obeyed. 

3.  Just  as  the  other  mode  is  inconvenient  in  oral  surgery. 


DR.  miller's  conclusions.  291 

so  in  perineal  operations  is  the  apparatus  needed  for  this 
method  in  the  way, 

4.  In  abdominal  surgery,  or  if  there  be  marked  intestinal 
lesion,  this  mode  is  contra-indicated. 

6.  The  inapplicability  in  cases  of  accident  and  emergency, 
when  time  cannot  be  allowed  to  prepare  the  bowel,  has  already 
been  mentioned. 

6.  Diarrhoea  has  been  noted  in  seven  out  of  the  thirty-seven 
cases  on  record,  though  in  none  of  the  writer's. 

We  believe  this  sequel  is  due  to  pre-existing  intestinal  lesion, 
to  the  lack  of  preparation,  to  a  too  great  distension  of  the 
bowel,  or  to  the  accidental  introduction  of  ether  in  liquid 
form.  Furthermore,  our  method  has  differed  from  that  of 
other  experimenters  in  this  respect — that,  instead  of  allowing 
the  vapor  to  remain  indefinitely,  we  secured  a  constant  change 
by  using  a  recurrent  catheter,  and  introducing  a  certain  quan- 
tity, or  permitting  it  to  escape,  as  indicated. 

Other  points  of  advantage  and  disadvantage  may  occur  in 
later  experience,  and  to  other  observers,  and  new  dangers  may 
be  discovered  ;  but  we  are  convinced  that  this  method  is  worthy 
of  further  trial,  and  will  find  its  place  in  surgery,  fulfilling  its 
own,  though  not  all,  indications.  Like  all  else  in  therapeu- 
tics, it  must  pass  through  the  stages  of  bungling  use,  condem- 
nation and  revival. 

Dr.  Miller's  form  of  apparatus,  see  Plate  23,  which  he  had 
made  by  Charles  Lentz  &  Sons,  No.  27  South  Tenth  Street, 
for  this  purpose,  consists  simply  of  a  water-bath,  a  gradu- 
ated bottle  provided  with  a  funnel  and  valve  for  pouring  in 
the  ether,  and  a  supply-pipe  for  conducting  vapor  to  the  rec- 
tum. This  tube  terminated  in  a  straight  recurrent  catheter, 
the  exhaust  channel  of  which  is  controlled  by  a  valve.  The 
catheter  is  furthermore  provided  with  a  movable  collar  for 
pressure  against  the  anus,  it  having  been  found  that  the  vapor 
tends  to  escape  by  the  tube. 

The  following  are  Dr.  Miller's  conclusions  which  he  kindly 
sent  to  me  Jauuarj'  7, 1885 : 

"  I  am  unable  to  add  further  data  to  the  subject  of  rectal  ether- 
ization.    To  attempt  to  strike  a  balance  of  the  same  I  deem  as 


292 


ARTIFICIAL   ANESTHESIA. 


yet  premature.  The  mechanical  dangers  of  over-distension,  the 
difficulty  of  emptying  the  bowel  of  vapor,  when  a  suspension  of 
the  anoeslhetic  is  desired,  and  the  greater  caution  needed  in  the 
administration — all  these  points  I  have  already  mentioned  in 
my  paper.  There  are  only  a  few  points  to  which  I  would  fur- 
ther allude,  viz. : 

"  First,  as  to  rate  of  elimination  :    This  taking  place  by  the 
lungs,  no  matter  how  introduced,  would  be  more  rapid  than 
when  the  agent  is  inhaled,  inasmuch  as,  by  the  new  method,  the 
pulmonary  mucous  membrane  is  preserved  intact,  and  is  there- 
Plate  23. 


C.  Lentz.  Phila. 


fore  more  capable  of  osmotic  function  than  if  bathed  in  mucus, 
as  by  the  ordinary  way. 

"A  more  serious  objection  has  not  yet  been  referred  to — one 
based  upon  theoretical  considerations.  The  experiments  of 
Paul  Bert — now  already  classic — have  demonstrated  : 

"  1.  That  the  degree  of  anaesthesia  depends,  not  upon  the  ab- 
solute amount  of  the  agent  used,  but  upon  the  percentage  in 
the  blood,  and  therefore  on  the  tension  of  the  vapor  in  the 
atmoitphere  inhaled. 


HYDROBROMIC    ETHER.  293 

"2.  That  the  percentage  needed  to  suspend  respectively  the 
functions  of  animal  and  organic  life  bear  a  definite  ratio  to  each 
other — a  ratio  constant  for  each  of  the  known  anaesthetic  agents, 
and  for  species  of  animals  and  for  each  human  individual.  All 
between  the  two  percentages  mentioned  is  termed  the  manage- 
able zone. 

"  3.  That  most,  if  not  all^  the  undesirable  effects  of  an  anses- 
.thetic,  are  due  to  leaving  this  zone. 

"  4.  That  the  greatest  safety  is  therefore  in  mixing  the  cases 
beforehand,  as  has  long  been  done  by  Mr,  Spencer  Wells. 

"  If,  now,  ether  be  given  by  the  rectum,  it  will  be  readily  seen 
that  the  gauging  can  only  be  by  absolute  quantity,  and  not  by 
the  percentage  actually  in  the  blood.  We  could  never  know 
how  near  this  zone  is  to  being  exhausted.  ■  To  my  mind  this  is 
the  most  serious  objection  that  can  be  offered. 

"  Dr.  Frank  Foster  *  mentions  a  fatal  case — that  of  a  woman 
in  ordinary  health,  to  whom  etherwasgiven  for  a  minor  operation 
and  in  whom  the  autopsy  showed  a  condition  of  acute  ulceration, 
not  only  of  the  whole  large  intestine,  but  also  of  the  lower  por- 
tion of  the  small  intestine." 


CHAPTEE    XVIII. 

Hydrobromic  Ether  or  the  Bromide  of  Ethyl  (C2H.Br) — Chemical 
Nature,  Properties,  Decompositions,  etc. — As  an  Ansesthetic  in 
Labor,  in  Dental  Operations — Table  of  the  Purity  of  Various 
Specimens  of  Bromide  of  Ethyl. 

Hydrobromic  Ether  or  Bromide  of  Ethyl  (CjH.Br). 

Pkoperties. — Bromide  of  ethyl  (CjH.Br),  or  "hydrobromic 
ether,"  is  a  colorless  liquid,  with  an  agreeable  odor;  it  boils  at 
about  40.7°  C.  (105.8°  F.) ;  has  a  density  of  1.41 9  at  15°  C.  (59°  F.); 
the  boiling-point  and  density  are,  therefore,  intermediate  be- 
tween those  of  chloroform  and  sulphuric  ether. 

*  New  TorJc  Medical  Journal,  May  24,  1884. 


294  ARTIFICIAL  ANAESTHESIA. 

Transparent  and  colorless  liquid,  heavier  than  water  (Serul- 
las) ;  specific  gravity  1.40  (Lowig),  1.4733  at  0°  (Pierre) ;  vapor 
density  3.754  (R.  Marchand  J.  per  cm.  188) ;  very  volatile  ;  boil- 
ing-point 40.7°  C.  when  the  barometer  stands  at  757  mm. 
(Pierre) ;  has  a  strong  ethereal  odor  and  pungent  taste  (Serullas). 
According  to  Lowig,  its  taste  is  strongly  and  agreeably  sweetish, 
with  a  somewhat  burning  after-taste.  The  vapor,  when  inhaled, 
exerts  an  anaesthetic  action,  like  chloroform  (Robin,  Compt. 
Bend.  xxx.  669).  It  is  sparingly  soluble  in  water,  but  mixes  in 
all  proportions  with  alcohol  and  ether. 

Decompositions. — 1.  Vapor  of  hydrobromic  ether  passed 
through  a  glass  tube  at  a  low  red  heat  is  resolved  into  ethy- 
lene and  hydrobromic  acid  gas.  2.  It  burns  with  difficulty,  but 
with  a  beautiful  green  flame,  which  does  not  smoke,  a  strong 
odor  of  hydrobromic  acid  being  at  the  same  time  evolved. 
3.  It  is  not  decomposed  by  nitric  acid,  oil  of  vitriol  or  potas- 
sium.    4.  With  ammonia  it  yields  hydrobromate  of  ethylamine. 

The  hydrobromic  ether  or  bromide  of  ethyl  was  discovered 
by  Serullas,  in  1827,  but  received  no  special  attention  until  Dr. 
Thomas  Nunnelly,  of  Leeds,  reported  some  experiments  made 
with  it  on  animals  in  1849.  Dr.  Nunnelly  brought  the  subject 
again  before  the  profession  by  a  paper  read  at  the  meeting  of 
the  British  Medical  Association  in  1865,  in  which,  speaking  of 
it  in  conjunction  with  another  aniEsthetic,  he  said  he  had  for 
some  time  employed  the  one  or  the  other  in  all  the  principal 
operations  at  the  Leeds  General  Eye  and  Ear  Infirmary.  This 
was  at  a  time  when  chloroform  held  such  complete  sway  in 
England  that  no  importance  was  attached  to  Nunnelly's  ex- 
perience or  experiments.  He  had  no  one  to  follow  him  in 
using  it ;  and  we  hear  no  more  of  it  until  1876,  when  some 
experiments  were  made  with  it  in  France,  by  Rabuteau,  on  the 
lower  animals  ;  but  evidently  without  a  knowledge  of  the  fact 
that  this  had  been  done  previously  in  England  by  Nunnelly. 

The  writer  then  took  tbe  agent  up  without  the  knowledge  of 
the  experiments  of  Dr.  Nunnelly.  He  had  it  made  in  Phila- 
delphia by  Professor  Remington,  and  with  two  friends  began 
experimenting  in  September,  1877,  using  it  first  on  himself  and 
then  upon  his  patients.    When  pure,  bromide  of  ethyl  is  a  vola- 


HYDROBROMIC  ETHER,  295 

lile,  colorless  and  almost  uninflammable  liquid,  contrasting 
favorably  in  this  respect  with  sulphuric  ether,  the  highly  in- 
flammable and  explosive  properties  of  which  are  well  known. 
It  has  a  hot,  but  saccharine,  taste;  its  specific  gravity  is 
1.42,  and  it  boils  at  105.8°  Fahrenheit.  Its  boiling-point 
and  density  are  therefore  intermediate  between  those  of 
chloroform  and  ether.  After  satisfying  himself  as  to  its  effi- 
ciency and  safety  as  an  anaesthetic,  by  experiments  upon  him- 
self and  others,  the  writer  laid  the  subject  before  the  Penn- 
sylvania State  Medical  Society  in  1878,  and  a  record  of  ten 
cases,  with  his  conclusions,  was  published  in  the  volume  of 
their  transactions  for  that  year.  In  August,  1879,  he  brought 
it  before  the  British  Medical  Association  at  Cork ;  and  in 
September  of  the  same  year  presented  a  report  of  one  hun- 
dred cases  before  the  International  Medical  Congress  at  Am- 
sterdam, to  which  he  was  a  delegate  from  the  American  Medical 
Association.  Up  to  March,  1879,  when  the  second  edition  of 
his  work  on  ansesthetics  went  to  press,  he  had  published  a  re- 
port of  one  hundred  and  twenty-five  successful  cases  in  quite  a 
variety  of  surgical  operations,  and  had  not  only  employed  it  at 
bis  daily  ear  clinic,  but  also  in  the  Jefferson  Medical  College 
Hospital ;  and  he  administered  it  in  April,  1879,  to  a  patient  of 
the  late  Dr.  Samuel  W.  Gross,  at  the  public  clinic,  when  he  (Dr. 
Gross)  removed  a  hyoid  cyst  from  in  front  of  the  neck  of  a  child. 
Dr.  R.  J.  Levis,  who  was  at  this  clinic,  for  the  first  time  saw  it 
employed,  and  became  much  interested  in  its  use. 

The  writer  thus  compelled  chemists  to  make  it  by  producing 
a  demand  for  it,  and  gave  them,  through  Dr.  Greene,  a  good 
formula  for  obtaining  it  free  from  impurities.  He  induced  sur- 
geons all  over  the  country  to  try  it — and  especially  the  surgeons 
of  this  city — by  bringing  it  in  every  way  before  their  attention. 
The  whole  number  of  cases  in  which  it  has  been  employed  by 
himself  and  friends  was,  up  to  June,  1880,  some  eight  or  nine 
hundred. 

Then  followed  two  deaths,  but  neither  of  the  cases  reported 
by  the  late  Dr.  Sims,  or  Levis,  were  due  to  the  use  of  anaes- 
thetics per  se;  in  the  former  instance  because  of  the  very 
depressed  condition  of  the  patient,  and  in  the  latter  because 


296  ARTIFICIAL   ANESTHESIA. 

death  did  not  occur  until  many  hours  following  the  adminis- 
tration of  the  anaesthetic. 

But  in  connection  with  these  cases  we  know,  first,  that  Emmet 
[Gyncecology,  2d  edition,  p.  746)  called  the  attention  of  the  pro- 
fession to  the  danger  of  administering  anaesthetics  where  any 
disease  of  the  kidneys  exists,  because  of  the  active  part  taken 
by  these  organs  in  the  elimination  of  them. 

In  Dr.  Sims'  case  there  was  a  marked  scantiness  in  the  se- 
cretion of  the  urine,  and  on  post-mortem  examination  it  was 
found  that  she  had  acute  catarrhal  nephritis,  indicating  that 
the  kidneys  were  disabled  from  performing  their  function 
in  eliminating  the  ether;  hence  its  retention  in  the  econ- 
omy, with  the  subsequent  toxic  symptoms.  In  Levis'  case, 
it  seems  plain  that  a  simple  explanation  of  the  death  of 
the  patient  lies  in  the  fact  that  the  heart,  which  had  be- 
come so  enfeebled  from  exhausting  chronic  disease,  was  un- 
able to  bear  the  strain  of  the  powerful  depression  of  its  already 
diminished  powers  that  ensued  upon  the  administration  of  the 
anaesthetic,  and  as  a  consequence,  broke  down  under  the  exces- 
sive load. 

We  cannot  but  feel  disappointed  that  these  deaths,  not  pro- 
duced by  it,  should  have  been  associated  with  it,*  as  advantage 
was  taken  of  the  accidents  by  those  having  a  prejudice  against 
the  ether,  to  condemn  it  on   theoretical  grounds.f     In  several 

*"The  Bromide  of  Ethyl  aa  an  Anaesthetic,"  by  Marion  Sims,  M.D.,  LL.D,  New 
Tork  Medical  Hccnrd,  April  3,  1880. 

fin  the  discussion  following  the  report  of  the  fatal  case  by  Dr.  Sims  to  the 
New  Tork  Medical  Society,  Dr.  Squibb  undertook  to  account  for  the  poisonous 
effects  of  bromide  of  etiiyl  by  assuming  it  to  be  a  loosely  molecular  article,  easily 
decomposed  ;  that  thus  its  administration  is  prone  to  be  followed  by  an  impregna- 
tion of  the  system  with  brnmine  ;  and  that  if  it  remained  as  bromide  of  ethyl 
in  the  system  it  might  not  be  harmful.  This  theory  has  been  shown  to  be  based 
on  insufficient  grounds.  In  the  first  ])lace  Professor  Jungk  has  shown  that  bro- 
mide is  not  "a  loosely  molecular  article;"  that  in  fact  it  is  a,  very  stable  salt  (for 
a  salt  it  really  is),  and  very  difficult  of  decomposition  ;  much  more  difficult  than 
chloroform.  In  the  second  pi  ice,  the  assumption  that  anic.sthesia  is  due  to  a 
breaking  up  of  the  anaisthetic  into  its  elements  is  nothing  more  than  a  hypothesis, 
and  one,  too,  which  has  little  or  nothing  to  support  it.  The  fact  that  one  of  the 
characteristics  of  bromide  of  ethyl  is  that  it  is  perfectly  unirritating  to  the  bronchi, 
goes  to  show  that  it  is  not  decomposed  :  if  it  were,  the  bromine  in  its  composi- 
tion—one of  the  most  irritant  of  substances— would  certainly  manifest  itself  in  its 
effects  on  the  air  passages. 


DEATH   FROM    HYDROBROMIC   ETHER.  297 

instances  recently,  the  use  of  this  anaesthetic  has  been  attended 
with  persistent  vomiting  and  free  secretion  of  mucus,  though 
in  the  thousands  (peases  in  which  it  has  been  employed,  chiefly 
in  Philadelphia,  in  not  one  single  instance  has  it  caused  cere-  • 
bral  trouble,  or  any  of  the  symptoms  produced  by  the  action 
of  free  bromine.  We  have  experimented  upon  frogs,  cats,  dogs, 
rabbits  and  various  other  animals,  by  subjecting  them  to  an 
atmosphere  highly  charged  with  the  vapor  of  hydrobromic  ether, 
and  in  rare  instances  were  there  the  effects  as  described  above. 

In  the  case  of  death  under  the  employment  of  this  agent  in 
the  hands  of  Dr.  Levis,  we  do  not  think  he  was  doing  justice 
to  it  in  subjecting  the  new  anaesthetic  to  this  most  severe 
test.  He  knew  the  extreme  debility  of  the  patient,  and  that 
the  most  simple  nervous  shock  would  render  him  liable  to 
death.  Hundreds  of  patients  have  thus  died.  Again,  when  or- 
dinary ether,  chloroform,  or  other  anaesthetics  cause  fainting — 
which  was  no  doubt  the  result  in  this  case — artificial  respira- 
tion must  be  resorted  to.  We  are  reliably  informed  that  in 
this  instance,  the  movement  of  the  chest  walls  forced  the  pus 
which  was  in  this  man's  langs  into  his  bronchial  tubes  and  suffo- 
cated him.  We  are  also  very  sorry  that  the  valuable  agent, 
nitrite  of  amyl,  which  has  been  found  useful  in  such  cases,  was 
not  employed. 

The  following  report  of  the  case  will  be  of  interest: 

"  PniLADELPHiA,  June  2,  1880. 
"  Deputy  Coroaer  Beam  made  aa  Investigation  of  the  circum- 
stances, as  reported  in  The  Times,  of  the  death  of  William  Linderman, 
eighteen  years  old,  of  Schuylkill  County,  while  upon  the  operating 
table  at  the  Jefferson  College  Hospital  under  the  influence  of  the  new 
anassthetic,  bromide  of  ethyl,  and  about  to  be  treated  for  stone  in  the 
bladder.  He  had  been  for  about  sixteen  weeks  under  the  care  of  Dr. 
R.  J.  Levis,  one  of  the  strongest  advocates  of  the  new  ansesthelic, 
and  was  taken  to  the  hospital  by  his  direction.  Linderman's  health 
was  very  poor  at  the  time.  Dr.  Ames,  who  administered  the  bro- 
mide, said  an  incision  had  not  yet  been  made,  but  Dr.  John  B.  Roberts 
said  that  there  had.  The  patient  was  in  such  a  condition  that  some- 
thing had  to  be  done,  because  he  could  not  tide  over  the  hot  weather 
—96°  to  98°  in  the  shade. 

13* 


298  ARTIFICIAL   ANAESTHESIA. 

"  Dr.  J.  G.  Lee,  the  coroner's  pliysician,  testified  that  he  found  the 
brain  congested,  the  lungs  far  advanced  in  consumplion,  and  the  kid- 
nei/s  and  liver  enlarged,  and  two  huge  encysted  stones  in  the  bladder. 
'  His  opinion  was  that  they  could  not  have  been  safely  taken  out, 
Linderman  could  not  have  lived  over  a  week  or  two  at  any  rale.  Dr. 
Lee  said  further,  that  he  had  experimented  with  the  bromide  on  ani- 
mals without  bad  results.  In  bis  opinion  death  resulted  from  ex- 
haustion and  prostration,  the  results  of  phthisis.  The  jury  took  the 
same  view  in  their  verdict." 

As  is  well  observed  by  Dr.  Henry  M.  Lyman,  "  All  experi- 
ence shows  that  the  administration  of  anaesthetics  to  certain 
patients  is  attended  with  danger.  Even  sulphuric  ether  may 
prove  fatal  if  the  kidneys  are  seriously  damaged,  and  pulmon- 
ary disorganization  is  a  well-known  source  of  danger  during 
the  inhalation  of  antesthetic  vapor.  The  administration  of 
chloroform  to  such  a  patient  would  be  a  very  hazardous  under- 
taking. The  fatal  results  in  these  cases  cannot  be  charged 
against  the  particular  ansEsthetic  employed,  but  rather  against 
the  exhibition  of  any  ana33thetic  agent  whatever."* 

In  some  recent  experiments  on  animals,  we  crowded  four 
ounces  (the  quantity  stated  to  have  been  used  by  Dr.  Sims) 
upon  a  dog  by  means  of  a  tin  inhaler,  until  he  became  appa- 
rently dead,  with  no  perceptible  action  of  the  heart  or  lungs  ; 
but  the  expression  of  his  eye  was  clear  and  the  pupil  was  di- 
lated, while  there  was  no  secretion  from  the  eyes  or  nostrils. 
The  apparatus  was  removed  in  the  space  of  four  minutes,  and 
he  was  exposed  to  the  air,  when  at  once  he  began  to  breathe, 
and  by  the  end  of  six  minutes  he  had  almost  entirely  recov- 
ered consciousness.  The  dog  did  not  seem  much  inclined  to 
move  for  ten  or  twelve  minutes  afterw.irds.  While  this  dog 
was  only  partially  under  the  influence  of  this  ante«thetic,  having 
at  first  caught  the  inhaling  apparatus  between  his  teeth,  there 
was  a  good  deal  of  rigidity  and  slight  tetanic  movements  of  the 
extremities,  but  this  was  overcome  by  the  free  use  of  the 
ether. 

Now,  had  we  been  using  chloroform,  just  before  we  would 

*  "  Ai'lificial  Ana'slliesia  and  A uaest belies,"  pages  ^20,  221. 


CAEE   IN    ADMINISTRATION.  299 

have  been  ready  to  perform  any  experiments  upon  the  animal, 
he  would  have  beeoc  dead  ;  and  neither  the  removal  of  the  an- 
aesthetic, nor  exposure  to  air,  would  have  been  of  any  avail. 
Again,  if  Squibb's  rectified  and  absolute  ether  had  been  em- 
ployed, we  must  have  super-saturated  the  animal,  and  been 
annoyed  by  the  expectoration  of  large  quantities  of  mucus, 
which  in  one  recent  experiment  by  us,  was  foliowed  by  death. 
Then  we  frequently  have  seen  tetanic  convulsions,  with  great 
reduction  of  temperature,  requiring  several  assistants  to  hold 
the  patient,  from  the  use  of  ordinary  ether.  The  rapidity  of 
the  anaesthetic  action  of  hydrobromic  ether,  and  its  rapid  elim- 
ination from  the  system  by  the  lungs,  are  two  of  its  chief 
merits  for  all  operations  that  are  not  prolonged.  We  recom- 
mend pure  hydrobromic  ether  in  operations,  not  lasting  over  forty 
minutes.  For  operations  lasting  one  or  two  hours,  we  would 
advise  the  additional  use  of  sulphuric  ether,  commencing 
after  thirty  or  forty  minutes'  exhibition  of  the  bromide  of 
ethyl. 

There  is  one  great  advantage  in  the  use  of  this  agent,  that 
the  administrator  must  attend  to  the  anaesthetic  all  the  time  ; 
he  cannot  watch  the  operation,  and  forget  the  patient  for  a  few 
seconds;  his  whole  attention  must  be  given  to  keep  up  its 
action.  We  believe  that  patients  have  sometimes  been  stifled 
by  close  pressure  of  the  napkin,  wet  with  the  water  present 
in  ordinary  ether,  by  the  carelessness  of  the  person  giving  it, 
whose  attention  has  been  given  to  the  operation,  rather  than 
to  the  patient. 

As  an  anaesthetic  in  labor,  it  has  peculiar  advantages,  in  that 
it  is  so  rapid  in  its  effects :  the  patient  is  comforted  between 
the  pains,  but  never  passes  into  such  a  state  of  profound  anaes- 
thesia, that  she  is  not  aroused  by  the  expulsive  effort,  and  has 
all  her  consciousness  about  her;  and  there  are  none  of  the 
depressing  effects,  of  ether  or  chloroform.  It  is  also  most 
valuable  in  these  cases,  when  it  becomes  necessary  to  change 
the  position  of  the  child  ;  also  in  bringing  forward  the  neck 
of  the  uterus  into  its  proper  position.*    In  none  of  our  cases 

*"  Bromide  of  Ethyl  as  an  Anaesthetic  in  Labor,"  by  E.  E.  Montgomery, 
p.  312. 


300  ARTIFICIAL   ANAESTHESIA. 

was  there  disturbance  of  the  bowels,  or  pain  in  the  back  or 
head. 

Miiller,  of  Berne,  speaks  well  of  this  obstetrical  anaesthetic, 
which  he  has  used  in  sixteen  cases  of  primiparae,  and  six  of 
multipara}.  Reddening  of  the  face  and  acceleration  of  the 
pulse  were  frequeuLly  noted,  thus  giving  the  assurance  that 
cerebral  anemia,  as  in  the  chloroform-syncope,  need  not  be 
feared.  The  peculiar  analgesic  virtues  were  gratefully  com- 
mented upon,  especially  by  multiparte.  Ha^ckermann,  and 
Parnemann  [Schmidt's  Jahrbuecher,  No.  12,  1884),  express 
themselves  in  equally  eulogistic  terms  of  the  anajsthetic  in 
confinements. 

To  the  country  practitioner,  who  is  obliged  to  extract  teeth, 
or  perform  any  of  the  minor  operations  in  surgery,  it  is  a  great 
boon,  as  it  acts  like  nitrous  oxide  gas.  It  is  well  where  a 
number  of  teeth  a,re  to  be  extracted,  that  a  prop  of  hard  wood 
attached  to  a  string  should  be  used ;  so  as  to  prevent  such  an 
accident  as  once  occurred  in  Philadelphia  under  the  use  of 
nitrous  oxide  gas — the  swallowing  of  a  prop  of  cork.  It 
frequently  happens  in  the  use  of  hydrobroraic  ether,  that  when 
narcotism  is  not  very  profound,  that  the  muscles  of  the  patient 
become  rigidly  contracted.  This  condition  occurred  in  a  recent 
case,  when  we  administered  ^i  of  this  anaesthetic;  the 
operator's  finger  was  caught  and  pinched,  as  also  his  forceps; 
and  yet  before  operating,  he  could  touch  the  cornea  with 
impunity.  Although  the  impression  passed  away  very 
rapidly,  twelve  teeth  were  extracted  with  entire  success,  the 
patient  not  feeling  the  pain,  and  promptly  recovering  con- 
sciousness. 

In  the  following  case,  the  patient  went  under  it  very  kindly. 
The  patient  was  a  man  of  very  nervous  temperament.  With 
three  drachms  of  hydrobromic  ether,  anaesthesia  was  produced 
without  any  struggling;  and  in  four  minutes  from  the  time  he 
had  commenced  to  inhale  it,  the  dentist  had  extracted  ten 
teeth,  and  he  had  fully  recovered  consciousness,  and  without 
nausea,  although  he  had  just  eaten  a  breakfast  of  solid  food. 

In  a  recent  case  of  cataract  extraction,  the  patient  went 
beautifully  under  the  influence  of  the  anaesthetic,  extraction 


USE    IN    THE    MIDDLE    EAR.  301 

was  accomplished,  and  the  patient  recovered  so  as  to  be  able 
to  count  fingers,  yet  Swing  to  some  strong  coffee  which  she 
drank,  from  dyspeptic  symptoms,  or  the  swallowing  of  water 
soon  after  the  operation,  she  became  very  sick  at  her  stomach, 
and  vomited  for  almost  twenty-four  hours ;  and  yet  the  case 
did  well.  In  a  case  of  operation  for  torticollis,  for  a  woman, 
so  much  air  was  swallowed  with  the  ether,  that  as  a  con- 
sequence she  complained  of  pain  of  a  hysterical  character, 
in  lower  part  of  the  abdomen  ;  the  same  which  is  often  the 
result,  when  nitrous  oxide  gas  is  inhaled,  and  too  much  air 
admitted. 

In  a  letter  received  from  the  late  Dr.  J.  Patterson  Cassells, 
of  Glasgow,  a  distinguished  aurist,  and  a  surgeon  to  the  cele- 
brated Glasgow  Infirmary,  he  writes  that  he  has  used  a  specimen 
of  the  hydrobromic  ether,  which  we  gave  him  at  Cork,  as  vapor, 
in  diseases  of  the  middle  ear,  and  has  also  employed  it  as  an 
anaesthetic  with  success. 

As  we  have  before  stated,*  "  no  ancesthetic  can  be  used  with 
absolute  safety;^'  all  will  kill.  Chloroform  kills,  in  round 
numbers,  about  one  in  every  three  thousand.  Pure  ether  f 
is,  next  to  nitrous  oxide,  the  safest  ansesthetic;  see  table 
of  deaihs,  and  many  of  these  doubtful,  having  been  re- 
ported from  its  use.  %  But  it  requires  boldness  and  freedom  in 
its  administration  ;  if  slowly  or  ineffectually  administered  it  is 
apt  to  produce  a  free  secretion  of  bronchial  mucus,  which 
occasions  troublesome  coughing.  If  nitrous  oxide  is  admin- 
istered alone  as  a  prelude  to  ether,  the  secretion  of  mucus  is 
less  troublesome,  but  there  is  a  great  amount  of  venous  con- 
gestion, and  the  tissues  become  gorged  with  blood,  so  that  every 
incision  tends  to  bleed.  At  times,  also,  wild  excitement  is 
produced  by  the  gas.  Some  surgeons  use  the  mixture  which  is 
known  as  A.-C.-E.,  which   contains   one  part  by  measure  of 

*See  "A  Presumable  Ether-Death  from  Heart  Failure,"  by  John  B  Roberts,  M.D., 
Medical  News,  September  27,  1884;  by  the  same  author,  "Ether-Death,"  Medical 
Times,  June  i,  1881.  "Case  of  Death  following  the  Inhalation  of  Chloroform," 
reported  by  P.  L.  Helsman,  M.D  ,  Albany  (Ga.)  Medical  News,  September  27,  1884. 

t  Ether  fortior,  liquid,  94  per  cent,  of  oxide  ethyl,  6  per  cent,  of  alcohol,  and  a 
little  water. 

X  See  tables  at  the  end  of  Chloroform. 


302  ARTIFICIAL   ANJ=:STHESIA. 

absolute  alcohol,  two  of  chloroform,  and  three  of  Squibb's 
etlier.  This  is  not  simply  a  mixture  ;  the  absolute  alcohol,* 
99.4  per  cent.,  causes  a  solution  of  the  other  two,  and  they 
evaporate  together.  But  the  mixture  should  be  administered 
freely  from  a  cone  of  felt  or  flaunel,  with  a  paper  covering,  and 
the  desired  effect  should  be  produced  as  rapidly  as  possible. 
The  best  results  are  by  the  agents  which  produce  rapid  effects, 
and  which  are  as  rapidly  recovered  from.  No  other  has  pro- 
duced such  rapid  anaesthesia  as  the  hydrobromic  ether,  and  it 
is  the  most  rapidly  recovered  from. 

As  the  result  of  observations  and  experiments  with  the  bromide 
of  ethyl,  our  conclusions  have  been  that  one  hour  is  the  longest 
time  that  a  patient  can  remain  under  the  influence  of  this 
anaesthetic  with  safety.  In  the  case  of  potent  remedies  like 
morphine,  atropine,  hydrocyanic  acid,  etc.,  no  one  will  attempt 
to  ignore,  or  refuse  to  use  such  valuable  remedies,  because  in 
certain  individuals,  and  under  certain  conditions  of  the  system, 
they  produce  death. 

Can  we  in  all  cases  rely  on  the  experiments  on  animals,  as  a 
true  and  absolute  guide  to  determine  our  course  in  the  human 
being?  We  think  not;  for  it  is  a  well-known  fact,  that  many 
animals  eat  plants  which  are  deadly  poisons  to  man,  and  certain 
ansesthetics  are  fatal  to  dogs.f  Again,  certain  salts  taken  with 
impunity  by  man,  are  poisonous  to  animals.  The  results  of 
the  prolonged  experimental  use  of  ansesthetics  in  the  laboratory, 
even  when  of  two  hours'J  duration,  cannot  be  taken  as 
unquestioned  as  the  results  obtained  by  numerous  careful 
observers,  on  themselves,  and  others.  Clinical  experience  has 
now  reached  at  least  ten  thousand^  well  authenticated  cases  in 
which  the  bromide  of  ethyl  has  been  employed,  with  safety, 
since  1880,  when  the  two  deaths  were  reported. 

♦Specific  gravity,  .0710,  at  77°  F. 

■f-  Dr.  B.  A.  'Watsdn,  Jersey  City.  "  An  Experimental  Study  of  Anaesthetics." 
Medical  Xeira,  p.  313,  May,  1878.     Method  not  given. 

J "  Two  New  Anaesthetics,"  hy  J.  C.  Eeeve,  M.D.,  Dayton,  Ohio.  Cincinnati 
Lancet  and  Clinic. 

gDr.  Chisholiii,  of  Baltimore.  Marylnnd  Med.  Jour.,  January,  1883.  Dr.  Prince, 
of  Jacksonville.  St.  Lottis  Med  and  ^"ur</.  Jour.,  October,  1883,  and  Dr.  L.  Turnbull, 
of  Philadelphia.     Medical  Bulletin,  June,  1880. 


EXPERIMENTS    BY    DR.    REEVE.  303 

The  following  trials  of  this  anaesthetic  were  made  by  Dr.  I.  C. 
Reeve,  to  test  its  merits  and  to  obtain  personal  experience  of  its 
effects.  They  were  made  by  a  gentleman  very  familiar  with  all 
the  other  ansesthelics,  and  his  experience  hhould  be  worthy  of 
confidence.  For  the  record  of  occurrences  after  loss  of  conscious- 
ness, and  for  care  and  attention  during  administration,  he  was 
indebted  to  his  friends,  Drs.  Pilate  and  Conklin. 

FiEST  ExPEBiMENT. — March  14th.  Four  hours  after  eating 
a  moderate  breakfast,  he  proceeded  to  inhale  the  bromide  of 
ethyl  in  the  recumbent  position  ;  and  from  a  bottle  just  opened, 
labeled  "  1  oz.  bromide  ethyl,"  about  one-fourth  of  the  contents 
was  poured  into  an  Allis'  ether  inhaler.  The  first  and  imme- 
diate sensations  upon  inhaling  it  were  a  sharp,  pungent  impres- 
sion on  the  air-passages,  a  sense  of  warmth  rapidly  extending, 
and  exhilaration.  With  the  second  inspiration  he  felt  a 
decided  influence  upon  the  brain,  and  began  to  talk  ;  anxious 
to  continue  speaking  as  long  as  possible,  and  to  state  his  sensa- 
tions. A  rapid  beating  in  the  ears  is  a  constant  symptom  with 
him  in  taking  chloroform,  and  immediately  precedes  entire  loss 
of  consciousness.  He  marked  its  presence  now,  and  also  its 
early  appearance.  It  could  not  have  been  later  than  the  third, 
or  possibly  the  fourth,  inspiration  when  he  noted  it,  and  this, 
as  with  chloroform,  was  the  last  sensation. 

Upon  opening  his  eyes  after  recovery  from  the  anaesthetic, 
he  immediately  collected  himself,  and  could  remember  all ; 
could  talk  clearly,  and  had  no  confusion  of  thought.  He  felt 
a  slight  sense  of  nausea  and  a  feeling  of  languor.  Eight 
minutes  afterwards  he  got  up  and  walked  about  without 
dizziness,  and  was  confident  he  could  have  done  so  sooner. 
He  did  not  attempt  it  sooner  because  he  felt  that  sickness 
would  ensue  if  he  arose.  The  feeling  of  nausea  remained 
until  he  commenced  eating  his  next  meal,  about  forty  minutes 
later. 

Second  Experiment. — Pulse  at  beginning,  80 ;  he  having 
just  ascended  a  flight  of  stairs.  Two  drachms  administered. 
Symptoms  began  to  be  manifested  after  two  respirations. 
Spoke  of  general  warmth,  pleasant  sensations  and  beating  in 
the  ears.     Anaesthesia  produced  in  one  minute  and  a  quarter ; 


304  ARTIFICIAL   ANAESTHESIA. 

in  another  quarter-minute  it  was  profound,  as  tested  by  a 
knife-point.  Pulse  during  the  first  minute  ran  up  to  nearly 
100,  then  fell  during  the  next  minute  to  about  70,  feeble  and 
intermittent.  Pupils  unchanged;  normal;  no  struggling  or 
excitement,  but  tetanic  clutching  of  the  inhaler  so  that  it  could 
be  gotten  away  only  with  difficulty.  The  anaesthesia  lasted 
one  minute  and  a  half.  He  then  awakened  without  mental 
confusion.  Pulse  seven  to  eight  minutes  later,  64.  He  was 
not  satisfied  with  this  experiment,  particularly  in  regard  to  the 
irregularity  and  intermittence  of  the  pulse — not  a  very  assuring 
symptom  in  ani^sthesia,  and  a  result  not  agreeing  with  other 
observations.  He  had  a  suspicion  from  this  fact,  and  from  the 
nausea,  that  the  specimen  used  was  not  pure.  The  bottle  bore 
the  name  of  a  house  which  is  always  a  guarantee  of  the  good 
quality  of  medicines ;  but  in  the  early  period  of  manufacture 
of  a  new  article,  it  would  not  be  surprising  if  perfection  was 
not  immediately  attained;  he  therefore  obtained  another 
specimen,*  and  one  week  after  the  above  trial  again  inhaled 
it. 

Third  Experiment. — Being  in  the  recumbent  position,  four 
hours  after  eating,  one  drachm,  by  measure,  was  pouied  into 
Allis'  inhaler.  He  tried  to  take  it  slower  this  time,  and  count 
the  respirations  aloud  to  mark  when  conscious  action  ceased. 
He  immediately  felt  the  same  grateful  and  pervading  glow  of 
warmth  all  over  the  body  ;  counted  to  the  seventh  respiration ; 
beating  in  the  ears  was  again  the  last  recognized  impression. 
Pulse  before,  80;  at  the  end  of  the  first  minute,  120;  one  and 
a  half  minutes,  at  the  rate  of  100;  at  the  end  of  two  minutes, 
78;  no  irregularity  or  intermittence;  pupils  unaffected;  totally 
unconsdous  in  one  minute.  Consciousness  returned  in  three 
minutes. 

It  was  his  design  to  push  the  inhalation  farther  this  time,  and 
to  test  the  muscular  relaxation,  as  well  as  to  decide  in  regard  to 
the  irregularity  of  the  pulse.  Feeling  that  this  had  not  been 
done,  after  about  fifteen  minutes  he  took  it  again. 

Fourth  Experiment. — Two  measured  drachms  were  poured 

♦From  the  house  of  John  Wyeth  &  Bro.,  Philadelphia. 


EXPEEIMENTS   BY   DE.    REEVE.  305 

on  the  inhaler,  and  he  placed  it  over  his  mouth  and  nose.  The 
impression  was  much  stronger  on  the  nose  and  air-passages, 
and  the  first  inspiration  made  hira  cough.  He  then  counted  to 
the  third  inspiration,  and  was  gone.  Pupils  the  same  as  be- 
fore, unaffected;  pulse  before  taking,  78;  at  the  end  of  the  first 
minute,  124;  one  and  a  half  minutes,  100;  and  of  two  minutes, 
78;  no  irregularity  or  intermittence.  Anaesthesia  in  one  minute. 
At  the  end  of  three  minutes  from  the  beginning,  he  got 
up,  and  walked  across  the  room,  and  could  have  remained  up. 
As  an  effort  at  prolonged  anaesthesia,  this  was  not,  therefore,  a 
success.  In  eighteen  minutes,  he  was  on  his  way  driving  to  see 
a  patient.  He  had  not  the  slightest  nausea  after  these  two  in- 
halations; felt,  if  anything,  better  than  before. 

Fifth  Experiment. — His  next  trial  of  the  agent,  and  first 
attempt  at  administration,  was  not  satisfactory.  The  patient 
was  a  man  aged  about  50,  a  wiry,  muscular  fellow,  of  the  type 
and  build  likely  to  give  troublesome  manifestations  with  any 
anaesthetic.  He  was  placed  on  the  table  for  an  operation  for 
haemorrhoids,  by  Dr.  Conklin,  who  had  brought  with  him  for 
the  operation  a  large  conical  sponge,  with  which  he  was  in  the 
habit  of  giving  the  A.-C.-E.  mixture.  Upon  this  he  poured 
two  drachms  of  hydrobromic  ether  and  placed  it  over  the  pa- 
tient's mouth  and  nose.  After  one  long,  deep  inspiration,  his 
face  became  deeply  flushed,  and  he  soon  began  to  talk  and  then 
to  shout.  More  of  the  liquid  was  poured  on  the  sponge;  but 
his  movements  interfered  with  the  inhalation  of  it  with  prompt- 
ness; muscular  rigidity  then  came  on,  and  was  marked;  respi- 
ration was  very  nearly,  if  not  quite,  stopped  for  a  time  by  te- 
tanic spasm  of  the  chest.  These  symptoms  were  almost  as  bad 
as  are  ever  seen  from  ether,  chloroform,  or  the  mixed  vapors. 
The  doctor  had  seen  worse  muscular  action  and  rigidity,  but  this 
was  as  bad  as  generally  met  with.  During  this  time  the  ether 
was  rapidly  added  until  the  supply  was  exhausted  (13  drachms), 
and  sufficient  relaxation  was  not  produced  to  make  the  opera- 
tion feasible.  No  observations  could  be  made,  of  course,  of  the 
patient's  pulse.  He  recovered  consciousness  qiiite  rapidly,  as 
compared  with  other  anaesthetics,  and  suffered  no  unpleasant 
after-effects. 


306  ARTIFICIAL   ANAESTHESIA. 

Tbis  was  not,  of  course,  a  fair  trial  of  the  remedy.  The  mode 
of  administration  was  decidedly  faulty.  It  is  an  ether,  and 
must  be  given  as  an  ether;  and  that  this  is  imperative,  is  the 
lesson  to  be  learned  by  this  failure. 

Our  personal  experience  with  hydrobromic  ether  fully  sus- 
tains the  observations  of  others  as  to  its  exceeding  promptness 
of  action,  and  the  rapidity  with  which  recovery  from  its  effecis 
takes  place.  It  is  also  more  pleasant  to  inhale  than  chloroform, 
which  is  not  very  disagreeable,  and  infinitely  pleasanter  than 
ether. 

In  our  own  experiments  on  animals,  we  found  that  frogs, 
placed  in  a  watery  solution  of  ethylic  bromide,  become  as 
completely  anaesthetized,  as  if  they  were  immersed  in  an 
aqueous  solution  of  chloroform.  Berger,  states,  to  the  Societe 
de  Chirurgie  {Le  Progr^s  Medical),  that  he  had  been  impressed 
by  the  rapidity  with  which  these  animals  succumbed  to  its 
vapor.  Terrillon  administered  the  vapor  of  ethylic  bromide  to 
eighteen  dogs,  without  accident  to  any  one  of  them. 

Dr.  Ott,  of  Easton,  Pa.,  who  has  made  thorough  and  scienti- 
fic researches  with  the  bromide  of  ethyl,  experimenting  upon 
frogs  and  rabbits,  believes,  that  the  increased  frequency  of  the 
pulse  is  due  to  stimulation  of  the  accelerative  nerves,  or  of  the 
cardio-raotor  ganglia,  and  the  dangers  in  administering  the  drug 
are  less  than  those  of  chloroform. 

W.  H.  Kingston,  Montreal,  Canada,  has  used  no  other  anaes- 
thetic, since  commencing  the  use  of  bromide  of  ethyl.  There 
is  less  resistance,  and  struggling,  on  the  part  of  the  patient. 
Vomiting  is  less  frequent.  It  is  eliminated  from  the  body  more 
rapidly,  than  any  anaesthetic,  except  laughing  gas. 

"  Bromide  of  ethyl  is  one  of  the,  and  in  some  respects,  the, 
most  valuable  anaesthetic  hitherto  used." 

In  Terrillon's  experiments,  muscular  relaxation  occurred  in 
human  beings  in  two  or  three  minutes ;  at  times,  there  was  con- 
gestion of  face,  neck  and  upper  part  of  the  chest.  The  pupils 
did  not  contract,  but  were  dilated.  The  pulse  was  always 
quickened,  and  every  fresh  dose  caused  fresh  acceleration. 
Respiration  was  always  hastened,  and  a  hyper-secretion  from 
the  buccal  and  pharyngeal  glands  took  place.    Sensibility  and 


DR.  wood's  experiments.  307 

consciousness  returned  with  great  rapidity ;  vomiting  was  not 
uncommon,  both  during  insensibility,  and  sometimes  for  hours 
after.  Verneuil,  at  the  same  meeting  of  the  Societe  de  Chirur- 
gie,  stated  that  one  patient,  a  woman,  to  whom  he  liad  given 
the  vapor  of  ethylic  bromide,  was  asleep  in  an  instant;  and 
Terrillon,  stated,  that  antesthesia  maybe  produced  in  less  than 
a  minute.  In  our  own  experiments,  the  shortest  time  necessary 
for  primary  antesthesia  was  thirty  seconds. 

Dr.  I.  S.  Stone,  of  Lincoln,  Va.,*  remarked  that  for  opera- 
tions requiring  only  a  few  moments,  he  preferred  bromide  of 
ethyl,  to  ether  or  chloroform.  He  thinks  it  much  safer  than 
chloroform,  and  it  does  not  carry  with  it  the  dangers  attributed 
by  Dr.  Wellford,  to  ether. 

Dr.  H.  C.  Wood  found,  by  experiments  upon  animals,  that 
if  the  vapor  of  ethylic  bromide  be  given  with  moderation, 
anaesthesia  may  be  produced  without  notable  reduction  of 
blood-pressure.  He  further  observes  ( The  Th.  Gazette,  June  15, 
1885):  "After  mixing  with  olive  oil,  and  agitating  and  distill- 
ing the  liquid  with  this  precaution,  we  can  obtain  a  safe  and 
powerful  anaesthetic,  well  adapted  to  cases  of  minor  surgery, 
which  do  not  warrant  the  exhibition  of  ether,  and  chloroform, 
and  particularly  eligible  in  obstetrical  practice."  In  the  experi- 
ments of  Dr.  C.  C.  F.  Gay,t  of  Buffalo,  the  agent  employed  was 
evidently,  from  color  and  taste,  impure,  as  was  also  that  used 
by  Dr.  D.  C.  Wilkinson,!  of  Galveston,  Texas.  In  Dr.  I.  C. 
Moore's  cases,  the  ethyl  was  abandoned  for  ordinary  ether,  even 
when  the  insensibility  had  not  passed  off,  owing  to  the  exhibi- 
tion of  so-called  bad  symptoms,  great  excitement,  with  intense 
and  persistent  retching  and  vomiting,  with  venous  engorgements. 
The  article  was  stated  to  be  pure,  and  was  from  Wyeth  &  Bro- 
ther. The  bromide  of  ethyl  is  costly,  from  the  great  care  re- 
quired in  its  preparation;  and  the  great  demand  for  it,  has 
caused  many  imitations  to  be  placed  on  the  market.  The  im- 
portance of  its  purity,  was  at  first  so  little  understood,  that  the 
original  manufacturers  did  not  take  sufficient  time  to  purify  it, 

*  Discussion  of  Dr.  McGuire's  paper.    See  Chloroform, 
t  Medical  Record,  July  17,  1880. 
t  Medical  Record,  May  15,  18S0. 


308  ARTIFICIAL   ANESTHESIA. 

80  that  for  a  time  the  article  contained  carbon  bromide  (C^B^), 
and  free  bromine,  phosphorus,  and  broraoform.  *  These  were 
found  in  the  specimen  employed  by  Dr.  Sims,  which  was  a 
brown  acrid  liquid,  with  a  pungent  and  disagreeable  odor. 
Twenty  drops  of  this  given  to  a  rabbit  which  had  previ- 
ously taken  two  grammes  (thirty  grains)  of  pure  ethylic 
bromide  without  the  slightest  ill  effect,  produced  irritation 
of  the  gastro-intestinal  tract,  followed  by  death  in  eighteen 
hours.f 

That  ethylic  bromide  may  be  employed  with  ease  and  success, 
has  been  abundantly  proved  by  the  experience  of  many  ob- 
servers. M.  Bourneville,  has  administered  it  to  a  large  number 
of  patients  in  the  Salpetriere  Hospital,  for  the  arrest  of  paroxys- 
mal hysteria  and  epilepsy.  He  has  also  administered  it,  daily 
by  inhalation  for  fifteen  or  twenty  minutes,  with  the  fortunate 
result  of  considerably  diminishing  the  frequency  of  the  convul- 
sive paroxysms.  In  several  of  these  cases,  the  temperature  was 
depressed  about  half  a  degree  centigrade,  during  the  act  of  in- 
halation. Immediately  after  the  withdrawal  of  the  anesthetic 
the  normal  degree  was  recovered,  and  sometimes  even  surpassed. 
The  pulse  in  about  five  hundred  administrations,  was  somewhat 
accelerated  during  the  period  of  inhalation.  In  six  instances 
only,  was  retardation  observed.  Respiration,  in  like  manner,  was 
almost  always  accelerated.  A  copious  overflow  of  tears  was 
nearly  always  remarked.  The  urine  never  contained,  either 
albumen,  or  sugar,  and  thequantityof  the  liquid,  was  not  affected. 
Rigidity  of  the  limbs  and  tremor  involving  the  upper  extremi- 
ties, were  sometimes  noted.  Daily  inhalations  for  a  period  of 
two  months,  exercised  no  unfavorable  influence  over  the  general 
process  of  nutrition ;  five  patients  found  their  weight  increased 
during  this  period. 

There  are  certain  preparatory  precautions  which  are  neces- 
sary to  the  safe  inhalation  of  the  bromide  of  ethyl : 

*  (See  tdbles).     ThiB  can  be  prevented  by  mixing  bromide  of  ethjl,  with  two  per 
cent,  of  olive  oil,  agitating  and  distilling  the  liquid  successively. 

fDr.  S.  Wolff,  Am.  Journal  of  Pharmacy,  May,  1880.     The  writer  also  obtained  a  ■ 
portion  of  the  same  liquid  from  Dr.  Wolff,  and,  on  comparing  it  with  the  specimen 
from  Dr.  Sims,  found  it  to  be  the  same. 


MODE   OF   EMPLOYMENT.  309 

1.  All  tight-fitting  garments,  in,  and  about  the  neck  and  chest, 
should  be  loosened. 

2.  The  saturated  ethyl  vapor  must  be  inhaled  almost  to  the 
exclusion  of  atmospheric  air.  The  best  form  of  inhaler  is  a 
thick  towel,  folded  in  the  form  of  a  cone,  closed  at  the  apex  with 
a  large  pin ;  between  the  folds  of  the  towel,  place  a  sheet  of 
newspaper.  The  base  of  the  cone  must  be  wide  enough  1o  in- 
clude both  mouth  and  nose. 

3.  Instruct  the  patient,  in  advance,  to  make  deep  and  long 
inspirations.  In  the  cone,  place  about  one  drachm,  by  measure, 
and  at  once  cover  the  nose  and  mouth  with  it,  and  do  not  re- 
move the  cone,  until  anaesthesia  is  produced,  which  will  be  in 
from  twenty  to  thirty  seconds. 

The  anaesthetic  sleep  will  not  last  more  than  from  two  to  three 
minutes.  The  patient  retains  the  usual  healthy  color  of  lips 
and  skin,  and  the  pulse  first  becomes  rapid,  then  slower,  and 
stronger,  as  the  narcosis  becomes  profound.  The  patient,  as  a 
rule,  awakens  suddenly,  and  completely;  but  if  there  is  nausea, 
or  much  agitation,  it  is  best  for  him  to  remain  quiet,  and  in  a 
horizontal  posture  for  some  time. 

Perhaps  no  operations  are  more  painful,  than  those  on  the 
eyes,  eyelids,  or  eyeball,  to  a  sensitive  person,  and  there  is  no 
anaesthetic  that  we  have  found,  so  applicable,  as  bromide  of 
ethyl  in  such  operations.  We  administered  it,  for  the  removal 
of  a  deep-seated  tumor  of  the  eyelid ;  the  operation  being  per- 
formed by  Dr.  Hermann  Knapp,  of  New  York.  The  patient 
took  the  towel,  with  about  two  drachms  of  the  ether,  in  her 
hands  and  applied  it  to  her  face,  and  in  thirty  seconds  she  was 
so  completely  anaesthetized,  that  she  was  not  conscious  of  one 
particle  of  pain  until  the  tumor  was  entirely  removed ;  she 
had  no  nausea  whatever,  or  any  other  disagreeable  symptom. 

Again,  in  operations  on  diseased  mastoid  cells,  we  have  em- 
ployed it  in  some  twenty  cases,  with  entire  success,  and  in  a 
very  recent  case  in  which  the  whole  bone  was  diseased,  and 
much  of  it  had  to  be  removed,  the  operation  being  of  a  most 
painful  nature.  We  administered  the  bromide  of  ethyl  to  this 
patient,  who  was  very  much  exhausted  by  profuse  discharge 
from  a  large  cancerous  growth.     The  patient  went  under  the 


310  ARTIFICIAL   ANAESTHESIA. 

influence  of  this  anaesthetic,  with  the  most  delightful  effect, 
not  suffering  at  all  from  the  operation,  and  going  to  sleep  after 
it  without  a  bad  symptom. 

We  have,  in  times  past,  heard  a  great  deal  of  the  injurious 
effects  of  bromides ;  and  for  a  time,  therefore,  we  gave  the 
hydrobromlc  acid,  and  ether,  with  great  caution,  never  exceed- 
ing thirty  drops,  three  times  a  day.  But  not  so  now  ;  experi- 
ence has  taught  us,  that  we  can  use  it,  if  well-diluted,  up  to  sixty 
drops,  three  times  a  day,  without  any  injurious  results.  To 
obtain  its  full  physiological  effects  in  epilepsy,  certain  cases 
of  pulsating  tinnitus  aurium,  and  in  preventing  the  disagree- 
able cephalic  symptoms,  occasioned  by  quinine,  and  iron,  in 
these  various  nervous  affections,  we  have  found  it  at  times  very 
satisfactory.  The  salts  of  this  agent,  bromine,  can  be,  and  are, 
used  with  the  greatest  freedom,  in  the  form  of  bromide  of 
potassium,  sodium,  and  lithium,  in  doses  of  grs.  xl-3vi,given 
in  six  days,  without  the  least  fear  of  its  injurious  effects  upon 
the  most  delicate  stomach ;  and  relieving,  as  by  a  charm, 
convulsions,  epilepsy,  whooping  cough,  sleeplessness,  head- 
ache, cerebral  disturbance,  tetanus,  and  all  forms  of  non-organic 
mental  derangement. 

As  is  well  observed,  by  Dr.  Chisholm :  *  "  For  office  use  I 
findthebromideof  ethyl,  invaluable,  on  account  of  its  prompt- 
ness, efficiency,  the  evanescent  nature  of  the  anaesthesia,  the 
absence  of  nausea,  and  the  perfect  comfort  with  which  pa- 
tients operated  upon,  can  leave  my  office  within  a  few  minutes 
after  the  etherization." 

Bromide  of  ethyl,  should  never  take  the  place  of  chloro- 
form, or  sulphuric  ether,  where  any  tedious  operations  are 
to  be  performed ;  but  there  is  no  reason  why  this  useful 
ancesthetlc  should  not  be  employed  in  all  operations  in  minor 
surgery,  and  in  those  on  the  eye,  ear,  throat  and  nose :  having 
everything  ready  in  advance,  so  that  the  patient  shall  be  aa 
short  a  time  as  possible,  exposed  to  the  evil  effect  of  an  an- 
aesthetic. 

*Maryland  Medical  Journal,  January,  1883. 


OBSERVATIONS   ON    BROMIDE   OF    ETHYL.  311 

Some  Recent  Observations  on  the  Use  of  Bromide 
of  Etliyl. 

"Szuman  of  Thorn  "  has  used  the  bromide  of  ethyl  since  1883, 
in  one  hundred  and  twenty  operations,  in  dentistry,  extraction 
of  teeth,  removal  of  small  tumors,  opening  of  abscesses,  scrap- 
ing of  the  sacs  of  tender  teeth,  etc.  He  applies  the  ethyl  with 
a  mask,  or  chloroform  inhaler,  using  from  ten  to  twenty  drops 
at  a  time.  Bzuman,  considers  bromide  of  ethyl,  indicated  in 
plastic  operations,  in  nervous,  or  timid  subjects,  as  it  is  so  agree- 
able to  the  smell  and  taste.  In  large  doses,  he  considers  it  as 
dangerous  as  chloroform,  or  ether. 

"  Eschawzier,"  an  assistant  to  a  dentist  of  Brooklyn,  had  the 
misfortune  to  lose  a  patient  from  this  mixture  of  bromide  of 
ethyl,  and  oil  of  roses,  so-called  soporative,  after  the  extraction 
of  a  tooth.  He  had  no  assistant,  and  operated  in  the  ordinary 
manner.  The  lady  recovered  from  the  anaesthetic,  and  shortly 
after  was  attacked  with  syncope,  and  choked.  Had  he  elevated 
her  feet  and  depressed  her  head,  or  drawn  out  the  tongue,  all 
would  have  been  well,  but  nothing  was  done,  as  no  medical 
man  was  present.  The  cause  of  death  was  stated  to  the  jury  as 
asphyxia,  and  pulmonary  congestion.  She  was  stated  to  have 
had  a  fatty  heart,  but  as  there  was  no  post-mortem,  we  do  not 
know  how  the  non-medical  man  arrived  at  this  conclusion. 
But  this  was  for  the  jury,  who  exonerated  the  dentist's  assistant, 
but  wisely  recommended  that  in  all  doubtful  cases,  the  patient 
should  be  examined  by  a  competent  medical  man,  before  the 
anaesthetic  be  administered. 

This  is  a  lesson  to  those  who  employ  mixtures,  which  are 
never  as  safe  as  the  agents  alone,  which  should  be  well  studied 
by  the  dental  or  medical  man,  before  being  employed.  (See  our 
remarks  in  Part  First,  on  this  subject.) 

The  following  are  the  conclusions  arrived  at,  in  1879.  Our  fa- 
vorable opinion  remains  unchanged  at  this  time,  after  using 
the  article  from  1878  to  1889  in  most  of  our  oflBce  operations. 

Minutes.        Seconds. 
Shortest  time  taken  to  place  a  patient 

under  the  primary  ansesthetic  influence,  0  30 

Longest  time, 5  00 

Average  time, 1  30 


312  ARTIFICIAL   ANESTHESIA. 

We  did  not  then  advise  that  bromide  of  ethyl  should  be  re- 
sorted to  in  protracted  operations,  and  we  never  have  employed 
it  in  any  case,  longer  than  forty  minutes,  and  have  never  used 
more  than  four  ounces  of  the  pure  ether,  in  one  case. 

The  Bromide  of  Ethyl  as  an  Aiifesthetic  in  Labor.* 

The  expression  of  Galen,  "Dolor  dolentibus  inutilis  est," 
has  ever  been  an  actuating  principle  in  the  practice  of  medi- 
cine, and  surgery,  and  would  undoubtedly  have  been  equally 
eft'ective  in  midwifery,  had  not  obstetricians  labored  for  ages, 
under  that  incubus  to  progress,  "  Meddlesome  midwifery  is 
bad." 

It  is  true,  there  is  now  no  question,  as  to  the  value  of  anaes- 
thetics in  irregularities  of  labor-pains,  in  eclampsia,  and  in  the 
various  operative  obstetric  procedures;  but  their  habitual  em- 
ployment for  assuaging  the  pains  of  natural  labor,  is  still  a 
much  mooted  subject.  We  are  not  confronted,  as  were  the 
earlier  advocates  of  an£esthesia,  with  the  charge  that  the  ar- 
rest of  labor-pain,  is  a  violation  of  divine  and  physiological 
laws,  retribution  for  which,  entails  upon  the  unfortunate  patient 
paralysis,  mania  and  other  bodily  ills;  but  it  is  apparent,  that 
anaesthesia  in  natural  labor,  is  not  only,  not  practiced,  but  op- 
posed, by  the  teaching,  and  practice,  of  the  majority  of  the 
profession  of  this  country.  In  the  discussion  of  a  paper  read 
before  the  Philadelphia  Obstetrical  Society  in  1879,  the  general 
sentiment  was  expressed  as  adverse  to  the  practice. 

It  may  be  asserted,  that  this  opposition  to  anaesthesia  in 
natural  labor  is  sufficient  evidence  that  such  practice  is  unde- 
sirable, but  we  need  only  quote  the  following  graphic  de- 
scriptions of  the  last  stage  of  labor  to  controvert  this  : 

Dr.  Merriman,  ("Synopsis  of  Parturition,"  p.  15)  says:  "The 
pulse  gradually  increases  in  quickness,  and  force ;  the  skin 
grows  hot;  the  face  becomes  intensely  red;  drops  of  sweat 
stand  upon  the  forehead,  and  a  perspiration,  sometimes  pro- 
fuse, breaks  out  all  over  the  body ;  frequently  violent  trembling 

*By  E.  K.  Jlontgomery,  M.D.,  late  Obstetrician  Philadelphia  Houpital,  Professor 
of  Didactic  and  Clinical  Gynaecology,  Medico-Cbirurgical  College. 


MONTGOMERY   ON   ANESTHESIA.  313 

accompanies  the  last,  and  at  the  moment  the  head  passes  into 
the  world,  the  extremity  of  suffering  seems  beyond  endurance." 
Denman  ("System  of  Midwifery,"  p.  103):  "The  distress  and 
pain  which  women  often  endure,  while  they  are  struggling 
through  a  difficult  labor  are  beyond  all  description,  and  seem 
to  be  more  than  human  nature  would  be  able  to  bear  under 
other  circumstances."  "  Mere  pain  can  destroy  life  "  (Gooch, 
in  Merriman's  "  Synop.  of  Parturition,"  p.  239),  as  is  shown  by 
the  report  of  women  delivered  in  the  Dublin  Lying-in  Hospital 
under  Dr.  Collins  :  "  Of  women  whose  sufferings  were  termi- 
nated in  2  hours  only,  1  in  320  died ;  where  labor  varied  in 
duration  from  2  to  6  hours,  1  in  145  died ;  in  those  in  whom  it 
continued  from  7  to  12  hours,  1  in  80  died;  where  it  endured 
from  12  to  24  hours,  1  in  26  died;  where  it  lasted  from  24  to 
36  hours,  1  in  17  died  ;  and  out  of  all  those  whose  parturient 
sufferings  were  prolonged  beyond  36  hours,  1  in  every  6  per- 
ished." ("  AniBsthesia  in  Surg,  and  Midwifery,"  Simpson,  p.  98.) 

Meigs  ("Prac.  of  Midwif.,"  p.  153)  says:  "What  do  you 
call  the  pain  of  parturition?  There  is  no  name  for  it  but 
agony." 

Finding  so  universal  assent,  as  to  the  severity  of  labor-pains, 
we  are  induced  to  seek  farther,  for  the  cause  of  the  non-admin- 
istration of  ansesthelics.  It  is  undoubtedly  based  upon  a  want 
of  confidence,  in  the  safety  of  the  various  alleviating  agents. 
Of  these,  chloroform  has  probably  been  the  most  frequently 
used  in  this  country. 

Anaesthesia,  in  obstetrics,  was  first  introduced,  and  actively 
championed,  by  Simpson.  The  frequent  fatality  from  the  use 
of  chloroform  in  surgical  practice,  and  the  influence  of  public 
opinion,  have  led  to  its  more  infrequent  use  in  obstetrics. 

Theoretical  reasons  have  been  given  why  chloroform  should 
be  perfectly  safe  in  labor;  but  are  all  dispelled,  when  cases  are 
reported,  as  they  have  been  by  Fagge  {Schmidt's  Jahr.,  No.  5, 
1860)  and  Curtin,  (Discuss.  Philad.  Obs.  Soc,  Dec.  4th,  1879), 
in  which  death  occurred,  as  a  result  of  its  administration. 

As  to  the  influence  of  chloroform  upon  the  uterine  con- 
tractions and  the  progress   of  labor,    there  has  been  great 
diversity  of  opinion.     It  has,  however,  been   certainly  dem- 
14 


314  ARTIFICIAL   AN.^STHESIA. 

onstrated,  that  profound  chloroform  narcosis  does  suspend 
involuntary  as  well  as  voluntary  muscular  contractions.  But 
complete  narcosis  is  unnecessary,  except  in  operative  proced- 
ures. In  natural  labor,  it  is  only  given  during  a  pain,  allowing 
the  patient  to  recover  consciousness  in  the  interval ;  but,  even 
80  administered,  there  is  a  general  feeling,  that  the  frequency 
of  uterine  inertia,  post-partum  hemorrhage,  is  thereby  greatly 
enhanced.  But  this  tendency  to  weakening,  and  after-hemor- 
rhage, is  not  so  significant,  as  to  outweigh  the  advantage  of 
relief  from  pain,  were  we  not  under  the  ban  of  the  relatively 
so  rare  evil  influences,  and  fatal  results  of  the  drug,  in  surgical 
cases. 

Although  ether  has  been  generally  preferred  to  chloroform, 
in  surgical  practice,  from  its  greater  safety,  it  is  less  desirable 
in  obstetrics,  for  the  reason  that  the  patient  must  be  profoundly 
etherized,  to  afford  relief.  A  small  quantity  of  ether,  removes 
the  woman's  moral  control,  without  alleviating  pain.  Tait, 
{Brit.  M.  J.,  vol.  ii.,  18S0,  p.  845)  directed  attention  to  the  fact, 
that  ether  passes  quickly  into  the  foetal  circulation,  and  in- 
creases the  peril  of  the  foetus.  He  cites  a  case  of  extra-uterine 
pregnancy,  operated  upon  under  ether,  in  which  the  foetus  was 
profoundly  hypnotized,  and  says  this  peril  to  the  child  from 
ether  was  indicated  by  Simpson. 

Klikowitsch  {St.  Petersb.  M.  Wochmschr.,  1880,  117  and  249) 
praises  a  mixture  of  nitrous  oxide  four  parts,  air  one  part,  as 
being  the  ideal  obstetric  anajsthetic  agent.  But  the  difficulty 
in  transporting  so  large  a  bulk,  and  the  necessity  for  a  special 
apparatus,  render  its  general  use,  in  private  practice,  improb- 
able. 

The  ideal  obstetric  anaesthetic,  is  one  which  will  act  rapidly, 
surely,  and  safely,  one  Avhose  effects  are  of  short  duration,  and 
that  can  be  carried  in  small  compass.  The  bromide  of  ethyl, 
answers  these  demands.  It  is  a  colorless,  not  unpleasant 
smelling  fluid,  which  when  breathed,  removes  the  sensation  of 
pain  without  destroying  intelligence.  It  was  quite  recently 
introduced  into  surgical  practice  in  this  country,  by  Drs.  Turn- 
bull  and  Levis,  though  its  anaesthetic  properties  had  long  been 
known. 


EABUTEAU   AND   LEBERT.  315 

Kabuteau,  studying  to  fix  its  physiological  action,  arrived  at 
the  following  conclusion  :  the  bromide  of  ethyl,  in  comparison 
with  chloroform,  is  better  borne,  is  more  rapid,  but  displaced, 
its  action  is  less  continuous,  and  is  eliminated  through  the 
lungs  much  more  rapidly. 

Lebert,  {Arch,  de  Tocologie,  June,  1882)  first  employed  it  in 
obstetrics.  He  published  four  cases — a  forceps  operation,  a 
version,  and  two  normal  labors — in  which  he  produced  complete 
absence  of  pain,  with  but  little  disturbance  of  the  sensorium. 
He  mentioned  that  he  had  tried  the  agent  for  a  long  time,  and 
spoke  with  such  enthusiasm,  that  others  were  induced  to  follow 
his  example. 

C.  Wiedemann,  (St.  Petersb.  M.  Wochenschr.,  1883,  No.  ii.) 
reports  a  series  of  seven  well-controlled  normal  labors,  and 
Hseckermann,  {Centralbl,  f.  Gynoek.,  1883,  No.  34)  has  tried 
the  drug  in  fifty  cases.  Both  concluded  that  it  could  be  used 
without  danger  to  mother,  or  child,  without  influence  upon  the 
course  of  labor,  and  without  loss  of  consciousness,  essentially 
diminishing  or  quite  removing  the  pains  of  labor.  They  pro- 
nounced it  the  long-sought-for,  and  yearned-after  means  for 
abrogation  of  the  curse  resting  upon  mankind,  "  with  pain 
shalt  thou  bring  forth  thy  children." 

Prof.  Muller  [Arch.  f.  Gynmk.,  Berl.,  1883,  xxii.,  99,  102  ; 
Berl.  Klin.  Wochenschr.,  83,  xx.,  673)  employed  it  in  twenty- 
two,  exactly  observed,  obstetrical  cases ;  sixteen  were  primiparse, 
and  six  multiparae,  all  of  whom,  were  quite  healthy.  In  nine 
cases,  a  trifling  acceleration  of  the  heart  and  lung  activity 
was  observed.  In  eight  cases,  dilatation  of  the  pupil  swiftly 
occurred,  and  very  frequently  the  face  became  red — a  circum- 
stance which  speaks  for,  rather  than  against  the  agent,  as  we 
ascribe  the  syncope  of  chloroform,  to  anaemia  of  the  brain.  The 
unpleasant  after-influences  of  chloroform,  as  pain  in  the  head, 
etc,  were  entirely  wanting.  Elimination,  appeared  to  occur 
almost  exclusively  by  the  lungs,  and  continued  over  the  first 
two  days  of  childbed,  producing  a  garlicky  odor  upon  the 
breath.  This  odor  could  be  distinctly  perceived  upon  the 
breath  of  the  foetus,  showing  that  it  had  quickly  passed  to 


316  ARTIFICIAL   ANiESTHESIA. 

its  circulation,  but  without  producing  the  most  trifling  effect 
upon  it. 

Miiller  did  not,  like  hia  predecessors,  find  the  drug  free  from 
disadvantage.  In  five  of  his  cases,  weakness  of  labor  was  in- 
duced, but  all  were  terminated  naturally.  No  hemorrhage 
followed,  nor  was  there  any  delay  in  the  process  of  involu- 
tion. More  important  still,  was  disturbance  of  the  respiratory 
organs,  during  convalescence.  One  patient,  to  whom  eighty 
grams  (flsij)  were  given,  complained  afterward  of  suffoca- 
tion and  headache,  and  was  annoyed  by  a  dry  cough.  Tem- 
perature and  pulse  were  normal,  with  regular  action  of  the  ab- 
dominal organs.  Coarse,  crepitant  rales,  were  heard  over  both 
lungs.  The  unpleasant  symptoms  had  vanished  by  the  tenth 
day.  The  second  patient,  to  whom  over  100  grams  (fl  3  iiss) 
were  given,  presented  more  serious  symptoms.  About  the 
third  or  fourth  day  of  convalescence  the  pulse  rose  to  100, 
temp.  39°  C.  (102^°  F.),  and  both  lungs  were  filled  with  large 
and  small  crepitant  rales,  without  phenomena  of  smothering. 
The  symptoms  vanished  with  profuse  expectoration,  and  the 
patient  was  discharged  at  the  end  of  two  weeks  well.  His  ex- 
perience further  showed  it,  not  always  effective.  Thus,  in  thir- 
teen cases,  in  which  it  was  administered  at  the  time  of  expul- 
sion, a  complete  result  was  obtained  in  but  five  cases,  three 
times,  pain  was  diminished,  but  in  five  cases  it  produced  no 
effect  whatever. 

We  have  used  the  drug  in  twenty-nine  cases,  and  have  become 
so  well  pleased  with  its  action,  as  to  regard  it  a  necessity  in  the 
practice  of  obstetrics. 

In  the  use  of  a  new  anaesthetic,  and  one  which,  from  its  re- 
cent use,  must  necessarily  be  regarded  with  suspicion,  we  have 
been  extremely  careful,  in  observing  and  noting  its  effects. 

Of  these  cases,  eight  were  primiparse,  and  twenty-one  multip- 
arse;  in  the  former,  delivery  was  completed  five  times  with 
forceps,  in  the  latter  eleven  times. 

Analyzing  these  cases  farther,  discloses  that : 

In  5,  ethyl  was  not  given,  until  the  forceps  were  applied  ; 

In  3,  labor  was  completed  naturally,  where  previous  labors 
were  instrumental ; 


HYDROBEOMIC    ETHER    IN    LABOR.  317 

In  1,  former  labor  was  also  instrumental ; 

In  3,  labor-pains  were  weak  before,  and  after,  administration 
of  the  drug  ; 

In  2,  pains  were  weak,  but  strength  greatly  increased  after 
its  administration  ; 

In  2,  the  foetus  presented  with  vertex  in  R.  O.  P.  position  ; 

Inl,   delivery   followed  by  uterine  inertia,    inversion    and 
hemorrhage ; 

In  1,  foetus  still-born  ; 

In  1,  child  died  same  day,  in  convulsions; 

In  1,  child  died  second  day,  of  cyanosis. 

In  the  presentation  of  any  anaesthetic  for  general  obstetric 
use,  the  profession  have  the  right  to  demand  that  it  shall  be 
shown  to  be  absolutely  safe  for  mother  and  child  ;  that  it  will 
not  cause  uterine  inertia,  thus  increasing  the  danger  of  post- 
partum hemorrhage  ;  nor  induce  acute  inflammatory  condi- 
tions in  the  organs,  by  which  it  is  eliminated,  complicating  the 
puerperal  stage. 

Of  our  cases,  three  deserve  especial  consideration ;  in  one, 
a  woman  of  delicate  physique,  who  had  been  supposed  to 
have  phthisis,  in  a  previous  pregnancy,  after  inhalation  of 
about  a  drachm  of  the  ethyl  during  three  pains,  began  to 
complain  of  a  sense  of  suffocation,  or  oppression  ;  respirations 
were  less  frequent  and  sighing ;  pulse  normal,  pupils  dilated. 
The  anaesthetic  was  discontinued,  and  labor  completed  nor- 
mally, but  the  sensation  did  not  wholly  disappear  until  the 
following  day.  The  second,  a  nervous  and  hysterical  primip- 
ara,  with  foetus  presenting  the  R.  O.  P.,  took  §  vi  between 
9.30  P.M.  and  2  a.m.,  when  the  delivery  was  completed  by  the 
forceps.  The  uterus  contracted  firmly.  There  was  no  lacera- 
tion of  vaginal  mucous  membrane,  or  perineum.  The  patient 
seemed  in  good  condition,  and  did  well,  until  in  the  afternoon. 
At  5.30  P.M.,  temperature  103°,  P.  152,  respirations  frequent, 
looked  badly,  abdomen  tympanitic,  bowels  had  been  frequently 
evacuated  unconsciously.  Quinine,  morphine  and  digitalis 
were  promptly  given,  and  vaginal  injections  employed. 

The  following  morning  her  temperature  was  normal,  pulse 
120.     Her  subsequent  improvement  was  undisturbed,  save  by 


318  ARTIFICIAL   ANAESTHESIA. 

the  want  of  control  of  the  bowel,  which  continued  for  nearly 
ten  days. 

The  third  patient,  a  primipara,  having  had  more  or  less  se- 
vere pain  for  twenty-four  hours,  without  the  os  dilating,  was  at 
12  M.  ordered,  R  Ext.  belladon.,  morphias  sulph.,  aa  gr.  ij  ;  01. 
theobromiB,  q.  s.  ft.  supposit.  no.  iv.  One  suppository  to  be  in- 
serted at  once,  and  another  in  the  evening.  At  10  p.m.,  we 
found  they  had  inserted  three.  She  was  then  experiencing 
the  effects  of  the  belladonna,  in  dryness  of  the  throat,  dilated 
pupils,  etc.  Pains  were  infrequent  and  feeble,  os  dilated 
slowly.  At  8  A.M.,  it  was  fully  dilated,  the  foetal  head  was 
driven  down  to  the  inf.  strait,  but  the  pains  were  insufBcient  to 
accomplish  more.  At  9.15  a.m.,  delivery  was  completed  with 
forceps.  The  ethyl  was  not  administered  until  the  applica- 
tion of  the  forceps,  and  was  continued  until  delivery.  After 
delivery  of  the  foetus,  the  uterus  was  flabby,  did  not  contract, 
and  bleeding  v/as  quite  free.  The  removal  of  the  placenta 
was  hastened  by  expression  and  traction,  upon  the  placental 
mass  by  two  fingers  in  the  vagina.  Shortly  after  its  delivery, 
continued  hemorrhage,  and  the  absence  of  a  uterine  tumor 
through  the  abdominal  walls,  led  to  a  vaginal  examination, 
which  disclosed  complete  inversion  of  the  uterus.  She  was 
quickly  given  the  ethyl,  and  the  uterus  restored,  by  pressing 
the  fingers  against  the  fundus  and  carrying  the  hand  into  the 
vagina,  while  the  uterus  was  held  by  the  external  hand. 

The  placenta  had  been  attached  to  the  posterior  surface, 
low  down.  The  uterine  cavity  was  washed  out  with  hot  water. 
She  recovered  without  special  difficulty. 

The  first  case  mentioned  was  one  unsuitable  for  the  admin- 
istration of  any  anaesthetic.  The  alarming  symptoms  of  the 
second  case,  we  are  inclined  to  attribute,  rather  to  the  shock  of 
a  threatened  peritonitis  than  to  any  deleterious  effects  of  the 
anaesthetic.  In  the  third  case  the  inertia  was  too  plainly 
present  before  its  use.  Although  the  ethyl  was  administered 
to  restore  the  organ,  it  became  at  once  quite  firm,  and  there 
was  no  subsequent  inclination  to  relaxation. 

There  was  a  foetal  mortality  of  three.  The  first  died  of 
cyanosis,  the  second  day   after    delivery.     It  wa^  small  and 


HYDROBROMIC  ETHER  IN  LABOR.       319 

poorlf  developed.  The  mother  had  been  under  treatment,  dur- 
ing the  last  three  months  of  pregnancy,  for  albuminuria ;  the 
labor  had  been  quite  tedious,  and  was  completed  by  forceps, 
with  some  difficulty.  The  other  two,  were  both  cases  in  which 
the  anaesthetic  was  only  given  durir.g  the  use  of  instruments; 
in  one  it  was  the  eleventh  pregnancy.  She  had  a  pendulous 
abdomen,  and  the  foetus  presented  the  vertex  in  R.  O.  P.  posi- 
tion. The  delivery  was  accomplished  after  considerable  diffi- 
culty. The  child  did  well  for  several  hours,  when  convulsions 
occurred,  and  death  followed.  The  other  was  a  primipara  seen 
in  consultation.  She  had  a  contracted  conjugate,  and  had 
been  in  labor  some  hours.  Her  attendant  had  made  three 
trials  with  instruments,  before  my  arrival.  The  head  was  de- 
livered after  hard  pulling,  the  cord  encircled  the  child's  neck, 
but  no  pulsations  were  perceptible  in  it.  The  greatest  diffi- 
culty was  experienced  in  delivering  the  body.  Prolonged  ef- 
forts were  made  to  resuscitate  the  child  without  avail. 

In  this  paper,  then,  we  are  able  to  enumerate  one  hundred 
and  twelve  cases  in  which  the  drug  was  used  without  any  fa- 
tality for  mothers,  and  with  but  three  deaths  in  children,  none 
of  which  could  be  attributed  to  its  action.  Fearing,  that  the 
unusually  large  proportion  of  operative  cases  in  our  series 
would  be  attributed  to  the  enervating  effect  of  the  drug  upon 
the  progress  of  labor,  we  have  looked  over  the  notes  of  the 
same  number  of  cases,  immediately  preceding  those  in  which 
the  anaesthetic  was  used,  and  find  that  twelve  of  them  were  op- 
erative. 

With  but  one  exception,  the  anaesthetic  was  not  employed, 
until  the  completion  of  the  second  stage  of  labor,  and  in  five, 
only  for  the  application  of  instruments.  The  only  case  of 
post-partum  inertia  was  one  of  these,  the  third  case  described 
above. 

The  ethyl  was  administered  with  the  advent  of  each  pain, 
by  holding  over  the  face  of  the  patient,  a  napkin,  on  which  a 
few  drops  had  been  poured.  This  was  removed  as  the  pain 
subsided.  There  was  no  choking  or  suffocation,  as  in  chloro- 
form, and  entire  absence  of  the  stage  of  excitement.  After 
one  inhalation,  the  patient  invariably  begged  for  it  with  the 


320 


ARTIFICIAL  ANESTHESIA. 


advent  of  each  recurring  pain.  With  small  quantities,  the 
sensation  of  pain  was  blunted,  while  intelligence  was  uninter- 
rupted; the  patient  was  perfectly  subject  to  control,  and  ready 
to  render  or  withhold  voluntary  efforts,  as  desired.  Under 
such  treatment,  the  expulsive  efforts  resembled  those  made  to 
evacuate  obstinately  constipated  bowels,  and  were  not  at- 
tended with  more  pain.  In  multiparaj,  the  usual  expression 
was,  that  they  had  never  known  such  relief. 

No  diminished  power  in  the  uterine  contractions  was  ob- 
served, subsequent  to  its  use;  in  fact,  in  many  of  the  cases  where 
before  the  contractions  had  been  ineffective  and  irregular,  they 
became  strong  and  regular.  In  one  case  we  attempted  to  deter- 
mine the  duration  of  pause  and  pain,  during  a  part  of  the  labor, 
by  palpation  over  the  abdomen,  with  the  following  result: 


BEFORE   ADMINISTBATION. 

Length. 

1^^  30^^^ 
Total  T.  17'^  iy^  Total  L.  8^^ 


Time  of  beg 

"nniDg. 

11' 

w, 

30"'  P.M. 

11' 

15'', 

45'" 

IV 

19" 

IV 

21", 

20'" 

IV 

22", 

45'" 

IV 

25", 

20'" 

IV 

27" 

IV 

28", 

45"' 

AFTEK    ADMINISTRATION. 


Tinne  of  beg 

nning. 

ll^ 

40", 

45'" 

11^ 

42", 

30"' 

11^ 

44", 

30'" 

11', 

4G", 

30'" 

11^ 

49", 

15"' 

11^ 

62" 

11^ 

54" 

11^ 

56" 

T.T 

16", 

30'" 

Length. 
30"' 


1" 
1" 


45"' 

30"' 
1.15 


T.  L.  7" 


It  was  difficult  to  determine  the  exact  length,  of  the  first  and 
third  pains,  after  administration  of  the  drug,  as  a  nausea  that 
had  existed  for  some  time,  then  culminated  in  vomiting.  The 
above  kind  of  observation  has  not,  however,  sufficient  power 
of  demonstration  to  decide  the  important  question,  whether  this 
agent  influences  the  character  of  the  labor-pains,  and  conse- 
quently, the  duration  of  the  labor. 

We  have  noticed,  a  marked  want  of  uniformity,  in  the  action  of 
different  preparations  of  this  drug.  Some,  procured  for  use  in 
the  Philadelphia  Hospital,  had  an  unpleasant  irritating  odor, 
and  was  slow  in  producing  the  anaesthetic  effect.    To  this  fact, 


DR.    PAREISH    ON    USE    OF   ANESTHETICS.         321 

we  are  inclined  to  ascribe  the  want  of  action,  experienced 
by  Miiller,  in  a  number  of  his  cases.  We  have  been  in  the 
habit  of  specifying  eitlier,  Wolff  &  Co.,  or  Parke,  Davia  & 
Co.,  when  procuring  it,  as  we  have  invariably  found  their 
preparations  of  the  drug,  with  a  pleasant  odor,  and  reliable  in 
action. 

We  feel  that  the  experience  derived  from  our  own  cases,  to- 
gether with  the  commendation  of  other  experimenters,  justify 
us,  in  urging  upon  the  profession,  a  more  extended  trial  of  this 
agent,  in  alleviating  the  sufferings  of  the  most  trying  period  of 
maternal  life- 

In  a  discussion  before  the  Obstetrical  Society  of  Pennsylva- 
nia, Dr.  W.  H.  Parish,  stated,  that  he  would  like  to  hear  more 
particularly  from  Dr.  Montgomery,  in  his  closing  remarks, 
respecting  the  safety  of  bromide  of  ethyl,  as  an  anaesthetic.  A 
few  years  ago,  it  was  introduced  into  surgical  practice  in  this 
city,  and  was  abandoned  in  consequence  of  its  dangerous  char- 
acter. If  dangerous  in  surgery,  why  should  it  not  be  in  obstet- 
rics also?  Chloroform,  which  was  at  one  time  considered 
perfectly  harmless  in  the  latter  class  of  cases,  has  been  found 
to  be  no  safer  there,  than  in  ordinary  cases. 

Dr.  Parish,  has  established  for  himself  three  rules,  respecting 
the  use  of  anesthetics  in  obstetric  cases :  1st,  In  easy  normal 
cases,  no  anaesthetic  is  required ;  2d,  If  the  patient  is  nervous, 
excited  and  uncontrollable,  he  gives  chloroform  at  the  incipi- 
eucy  of  each  pain,  to  quiet  the  excitability  of  the  patient,  and 
take  away  the  sharpness  of  the  pain,  without  producing  uncon- 
sciousness. During  the  intervals,  between  pains,  the  chloroform 
is  withheld.  3d,  Whenever  he  considers  that  unconsciousness 
(full  anaesthesia)  is  necessary,  he  employs  ether,  so  as  to  avoid 
the  depressing  eifects  of  chloroform.  Bromide  of  ethyl  might 
be  used  in  place  of  chloroform,  as  indicated  in  his  second  rule, 
if  shown  to  be  equally  safe ;  but  he  would  not  consider  it 
proper  to  use  it  to  produce  complete  relaxation,  as  required  for 
version,  or  the  application  of  the  forceps. 

Professor  Wood,  in  his  experiments,  found  bromide  of  ethyl 
more  dangerous  than  chloroform.  Dr.  Parish  does  not  use  it ; 
(Dr.  P.  did  use  it,  and  reported  such  cases  to  us)  and  he  fears 

14* 


322  ARTIFICIAL  ANESTHESIA. 

it  would  go  hard  with  any  physician  before  our  courts,  if  he 
had  a  fatal  accident  to  occur  during  its  use. 

Dr.  Montgomery,  in  closing,  said  that  as  to  the  danger  result- 
ing from  the  use  of  bromide  of  ethyl,  he  thoaglit  there  could 
be  none  if  a  pure  article  was  carefully  used.  The  patient  is 
not  completely  narcotized — consciousness  is  not  lost;  the  ad- 
ministration of  the  drug  is  interrupted.  The  patient  can  co- 
6perate,  although  relieved  of  suffering.  She  can  answer 
questions. 

Professor  Miiller,  is  the  only  one  who  has  failed  in  obtaining 
good  effects;  and  this  was  probably  due  to  impurity  in  the 
drug.  Bromide  of  ethyl  does  not  take  the  place  of  chloroform, 
nor  does  it  produce  muscular  relaxation,  nor  relaxation  of  the 
uterus,  as  required  in  version.  It  can  be  pushed  to  complete 
unconsciousness;  but  that  is  not  necessary,  as  pain  will  be 
relieved,  while  the  contraction  of  the  uterus,  and  respiratory 
muscles,  are  fully  as  effective  as  without  it.  Labor  is  undoubt- 
edly a  physiological  process,  as  much  so,  as  respiration  or  defe- 
cation, but  it  does  hurt. 

This  is  the  type  of  the  most  severe  and  agonizing  suflftring; 
and  we,  as  physicians,  are  called  upon  to  relieve  that  suffering, 
and  prevent  the  waste  of  vital  force,  to  the  extent  that  we  are 
able,  by  preventing  pain — long-continued  pain. 

Bromide  of  ethyl,  is  apparently  entirely  safe,  when  given  as 
we  have  used  it.  Experimental  physiologists,  do  not  all  agree 
with  Prof.  Wood,  as  to  the  comparative  danger  of  this,  and  other 
anaesthetics. 

Brom-Ethyl,  and  its  Value  in  Dental  Opei-ations. 

After  a  careful  discussion  of  the  merits  of  the  various  anaes- 
thetics, Dr.  Julian  Scheps,  of  Breslau,  gives  an  elaborate  ac- 
count of  brom-ethyl,  and  of  its  great  usefulness  as  a  narcotic 
in  dental  surgery.  {Centralblatt  fur  Chirurgie,  Sept.  24,  1887; 
Therapeutic  Gazette,  Dec.  15,  1887.) 

He  quotes  Dr.  H.  C.  Wood,  who  states,  that  brom-ethyl  has 
a  direct  paralyzing  effect  on  the  muscles  of  the  heart,  causing 
a  marked  decrease  of  the  pressure  of  blood,  and  therefore 
equally  as  dangerous,  as  chloroform. 


BEOMO-ETHYL    AND    DENTISTRY.  323 

Dr.  Scheps  agrees  with  us,  that  these  symptoms  only  occur, 
after  long-continued  inhalation,  and  he  holds,  that  the  drug  ia 
perfectly  safe  in  short  operations.  The  drug,  says  the  author, 
should  be  administered  in  the  same  manner  as  chloroform,  on 
an  Esmarch's  mask.  Terrillon,  advises  its  being  poured  on  a 
compress  which  covers  the  face,  but  Dr.  Scheps,  says,  the  mask 
only,  should  be  used  under  all  circumstances. 

The  patient  should  be  placed  as  horizontal  as  possible. 

The  author  then  gives  a  minute  description  of  several  re- 
markable cases,  and  gives  a  large  number  of  other  cases  in  tab- 
ular form.  All  these  cases  relate  to  the  extraction  of  diseased 
teeth. 

The  average  dose  of  brom-ethyl  required  to  produce  anaes- 
thesia, was  15  grammes  (4  drachms).  In  most  of  the  cases,  the 
patient  was  conscious  of  the  extraction,  but  experienced  no 
pain  whatever.  The  author  is  of  the  opinion,  that  in  intro- 
ducing brom-ethyl  into  dental  surgery,  he  has  brought  forward 
an  anaesthetic,  which  can  be  rivaled  by  none. 

A  great  drawback  to  the  extensive  use  of  brom-ethyl,  is  its 
peculiar  tendency,  to  cause  rigidity  of  the  jaws,  and  excessive 
secretions  of  mucus,  which  follow  its  use. 

As  an  anaesthetic,  nitrous  oxide  has  this  same  peculiarity,  so 
that  a  prop  must  in  all  instances  be  employed,  to  keep  the 
mouth  open  during  extraction. 

Various  mixtures  have  been  made  with  brom-ethyl,  and 
agents  employed  to  disguise  its  taste  and  smell. 

The  following  article  by  the  editor  of  the  Dental  Cosmos,  will 
reveal  a  fraud  practiced  by  a  member  of  the  dental  profession : 

Proprietary  ANiESXHEXics. — Our  attention  has  again  been 
called  to  this  subject  by  a  correspondent,  who  inclosed  a  circu- 
lar announcing  a  "new  discovery  for  producing  natural  sleep 
at  will ;  safe  and  efficient  for  extracting  teeth  without  pain  or 
danger;  indorsed  by  the  leading  medical -journals  in  Europe, 
and  America." 

The  proprietor  of  this  wonderful  agent,  claims  that  it  was 
discovered  after  years  of  labor  and  research ;  that  since  1864,  he 
has  been  constantly  on  the  alert,  for  some  agent  that  would  be 
more  efficient,  safe,  and  economical,  than  nitrous  oxide.    He 


324  ARTIFICIAL   AN^STHE-5IA. 

appends  statistics,  showing  its  relative  economy,  and  testimonials 
as  to  its  safety  and  efficiency.  He  claims  that  he  was  led  to  the 
investigations  which  resulted  in  the  discovery  of  this  new  an- 
ajsthetic  from  the  conviction,  that  "progressive  science  should 
devise  means  for  producing  natural  sleep  at  will,"  and  he  there- 
fore determined  to  investigate  and  discover,  if  possible,  some 
agent,  that  would  not  be  open  to  the  objections  which  appertain 
to  chloroform,  ether,  and  nitrous  oxide  gas,  all  of  which,  he  con- 
siders unsafe,  because  they  produce  congestion  of  the  brain,  and 
death  is  likely  to  result  from  such  abnormal  condition;  that  the 
new  anesthetic  produces  natural  sleep  without  congestion,  and 
is  therefore  absolutely  free  from  danger,  and  that  "heart  dis- 
ease, pregnancy,  lactation,  menstruation,  kidney  troubles,  and 
old  age,  are  no  drawbacks  in  its  administration."  The  discov- 
erer of  this  new  anaesthetic  has  given  it  the  name  of  "Sopora- 
tive,"  the  word  being  derived  from  the  Latin  soporo,  meaning 
natural  sleep,  as  we  are  informed  in  the  circular. 

Realizing  at  once  the  value  which  an  agent  of  this  character 
would  have  in  the  practice  of  medicine  and  dentistry,  we  pro- 
cured a  bottle  direct  from  the  proprietor,  at  a  cost  of  five  dollars, 
at  once  submitted  it  for  analysis,  and  have  received  the  follow- 
ing report  thereon : 

Philadelphia,  March  29,  1886. 
J.  W.  White,  M.D.: 

Dear  Sir : — The  sample  of  "  Soporative  "  received  from  you  on  the 
24th  inst.  has  been  examined.  It  is  Bromide  of  Ethyl,  flavored  with 
rose,  and  containing  distinct  traces  of  alcohol,  as  follows : 

Bromide  of  ethyl 99.13  per  cent. 

Alcohol  and  oil  of  rose 87    "     " 


100.00 

Yours  truly,  Henry  Trimble, 

Professor  of  Analytical  Chemistry  in  the 

Philadelphia  College  of  Pharmacy. 

(See  table  opposite.) 

Analysis  of  0.307  grammes  bromide  of  ethyl: 

C.  67.601 
H.  14.081 
Br.  225.322 

307.004 


Table  Sliowmg  Keactions  of  Commercial  Samples  of  Bromide  of  Ethyl 


1. 

2. 

3. 

4. 

5. 

6. 

7. 

8. 

9. 

Pora  Chloro- 
form. 

1.  Color  and  reaction. 

.iJshily'aoi'd. 

colorlMF, 

°SS: 

nSi'; 

noS; 

.lightly  eol-rd 

yelloivielicol" 

slightly  Boid. 

colorless, 

2.  Odor  after  oraporolion  from 
blottine  paper. 

plalniyorocB 

of  ally!  aal- 

phido. 

n.r.„,g. 

norotalgn 

alight  odor  of 
Rariiu. 

..ellssonr. 

compounds. 

.oforeig. 

noWelgn 

3.  SpeoiDc   grovity  at  15'  C. 

1.1210. 

1.^37. 

1.4iW. 

1.403. 

1.2314  atSFC 

~-k?k— 

i.  Coustatit  boiling  point. 

35=  C. 

a6>j°  c. 

'■  "S  a.r°""'  ■°°"'°' 

.Ueht^,^  nt. 

■"ffid"- 

BliBhtljat- 

slightly 

SI 

"ly'SXi" 

■S-r 

^  aHg'htiy.'^ 

.t-cLa. 

slightly 
attacked. 

=-^S"r„r.;if.'^r" 

•jlghtl:(^nlk. 
tiogtotlio 

Bligtit  roraigo 
odor,  Irrita- 

=S' 

line,  strong 
persiBIont 

'liS"'dc''raf 

pt'SlKn-g- 

fi^l'g.iriiDkj 
odor. 

"faiuUore^"^ 

no  foreign 

-c'S!'- 

'■  "ga'SSmU':'"""  ""''■ 

yolloiv. 

yoUow. 

yellow. 

yen™-. 

yellow. 

yellow. 

ted  belore  nd- 

yellow. 

yellowish. 

'  7lTith''eodiummtropraB3ide. 

coloration. 

yollow. 

yalloff. 

n.raaatl.n. 

no  reaetioa. 

no  reaction. 

blood  red  col- 

no  renclion. 

no  reaction. 

0.  KeactioD  with  cona.  milpha- 

9ES- 

'"rH.'Br!"' 

planoo^ooa- 

mct'o'th,'; 

"ane.'™; 

atrongly    irri- 

«-i'thllB''vBlT"n 

alightly  brown 
at  plane  Of 

"=• 

'XS- 

1(J.  With  Foiiling-s  solution. 

milky. 

•'»• 

ts:;s^ror 

coal  gas. 

"trring",'."' 

Blight^odor." 

nereaetion. 

slightly 

..reaction. 

™.'t'io°a°. 

"rajp'or!" 

"■  "KSnlmSmff."'''  "'■ 

«l..r. 

•laar. 

.1,.,. 

clear. 

clear. 

ol.or. 

precipitate. 

elear. 

clear. 

pScTJuM 

12.  Aqaeous  solution  of  potossu 

milk,. 

al..,. 

claar. 

InrUd. 

claar. 

inrhid. 

clear. 

al..r. 

beoomea 

""y'.iro"'.""' 
turbid^V- 

tnasio  pflrmangaDntti. 

ill 

S'?^KS: 

'7SfJ' 

'H? 

destroyed  in 

t3^SS 

3*/.  '" 

destroyed  in 

°  d.™.  ° 

"■  ^S°°aff'™S'°"'"° 

greeQish    eol- 

brown,  u^por 

yollow. 

layer  brown- 
iah  yellow. 

alight  grcen- 
of  other  layer. 

vEloC 

Isi^- 

hardly  notioo- 
able  turbidity. 

"•'••"-■" -^ '•■'""• 

be.om«t.r- 

.,..c. 

'"'Sr"" 

Clear. 

'".^''ttircid.'' 

s^ 

lC.Slt,.,..r.«vot.ol«tion. 

co.o«m.,Uy. 

npp„,;y.. 

tarhid. 

milky. 

milky. 

milky. 

i=;s!Si;j. 

.nSEy. 

clear. 

clear. 

17.Amm.ni...lnit,.t.„f.il,„. 

becomeB  tur- 

',a'a,^'S' 

"''milkyr' 

both  Inyerfl 
milky. 

milky. 

tnrhld. 

""fSS" 

ss 

clear. 

'"'t-nX" 

ulDtiugnitbBulphnricauid.l    to  db  odor.    1      ticeable. 

.light  .al- 
phurouB  odor. 

Bligbt  foniign 

captibie  odor. 

hardly  notice- 

iSy'tt"- 

nochnnge. 

nnchaage. 

REACTIONS    IN   TABLE.  325 


Estimated  from  formula  CjH^Br. 

C.  67.596 
H.  14.082 
Br.  225.322 


307.000 

Note,  explanatory  to  some  of  the  reactions  mentioned  in  this 
table : 

To  No.  6.  In  this  set  of  reactions  the  quantities  of  sodium 
and  ether  used  were  as  nearly  as  possible  alike. 

To  No.  6.  The  liquid  after  treatment  with  sodium  is  dropped 
on  blotting  paper  and  allowed  to  evaporate ;  foreign  substances 
betray  their  presence  by  the  odor.  The  irritating  property  of 
the  vapor,  when  referred  to,  is  meant  to  apply  mainly  to  its 
action  on  the  eyes. 

To  No.  7.  The  sample  is  first  left  in  contact  with  the  sodium 
amalgam  alone  ;  after  color  reactions  are  obtained,  the  water  is 
added.  This  sample,  we  may  remark,  was  furnished  Dr.  William 
Brodie,  of  the  Therapeutic  Gazette,  by  Dr.  J.  Marion  Sims.  It 
is  a  portion  of  that  employed  by  this  distinguished  surgeon  in 
the  fatal  case  with  the  details  of  which  the  profession  is  so  fa- 
miliar. 

To  No.  14.  The  ether  being  heaviest,  constitutes  in  this  case 
the  lower  layer. 

To  Sample  No.  7.  In  this  case  the  specific  gravity  was  taken 
at  20°  C.     All  the  rest  were  taken  at  15°  C. 

Postscript. — After  the  above  article  had  already  passed  into 
the  hands  of  the  printer,  Professor  Jungk  received  an  additional 
consignment  of  various  commercial  brands  of  bromide  of  ethyl. 
As  the  time  for  making  further  tests  was  too  limited  to  take  in 
hand  more  than  a  single  sample,  we  selected  for  the  purpose  one 
purporting  to  have  been  used  by  Dr.  Levis,  of  Philadelphia,  in 
the  fatal  case  which  he  has  lately  reported  as  having  occurred  in 
his  practice  from  the  effects  of  this  anaesthetic,  which  sample 
consisted  of  about  two  fluid  ounces,  and  was  contained  in  a 
bottle  with  the  name  "  Jefferson  Medical  College  Hospital " 
blown  in  the  glass.  The  reaction  obtained  with  this  sample 
resembles  very  much  that  of  No.  7  in  the  accompanying  table,* 

*  This  valuable  table  was  received  from  Park,  Davis  &  Co.,  of  Detroit. 


326  ARTIFICIAL    ANiESTHESIA. 

and  were  as  follows:  Colorless;  reaction  neutral.  On  cooling 
the  ether  to  20°  C,  it  became  opalescent,  and  on  being  allowed 
to  remain  at  rest  for  a  while  after  the  treatment,  a  separation  of 
a  liquid  substance  takes  place,  which  refuses  to  be  again  incor- 
porated with  the  main  body  of  the  ether  by  agitation. 

Water  agitated  with  the  sample,  acquires  a  decidedly  acid  re- 
action. The  specific  gravity  is  1.2123  at  15°  C.  This  sample 
begins  to  boil  at  33°  C,  but  the  boiling-point  does  not  remain 
constant  until  35°  C.  is  reached.  Sodium  was  strongly  at- 
tacked, with  the  formation  of  a  very  considerable  quantity  of 
bromide  of  sodium.  The  liquid  decanted  from  the  sodium  and 
evaporated  from  blotting-paper,  left  an  odor  similar  to  that  of 
acetic  ether.  Another  portion  of  this  liquid,  when  supersat- 
urated with  concentrated  sulphuric  acid,  evolved  vapors  of 
hydrobromic  acid. 

Sodium  amalgam  was  strongly  attacked,  with  the  formation 
of  a  white  flocculent  precipitate.  The  liquid  decanted  from 
the  sodium  amalgam,  gave  no  reaction  with  sodium  nitroprus- 
side.  When  the  ether  is  treated  alone,  with  concentrated  sul- 
phuric acid,  it  becomes  turbid,  and  also  colors  brown  at  the 
plane  of  contact. 

Half  a  fluid  drachm,  treated  with  five  drops  of  Fehling's  so- 
lution, changes  the  color  of  the  latter  to  a  light  green,  which 
cannot  again  be  restored  to  a  blue  by  the  addition  of  caustic 
soda. 

When  treated  with  an  equal  volume  of  alcoholic  potassa,  the 
ether  remains  clear  for  about  fifteen  minutes,  and  then  becomes 
turbid.  Agitated  with  aqueous  solution  of  potassa,  the  latter 
acquires  a  turbidity  ;  the  addition  of  potassium  permanganate, 
is  followed  by  an  immediate  green  coloration  of  the  liquid,  and 
after  about  half  an  hour,  by  the  formation  of  a  brown  precip- 
itate. 

No  reaction  is  obtained  by  treatment  with  sulphuric  acid, 
and  potassium  bichromate.  With  acetate  of  lead  solution, 
aqueous  as  well  as  alcoholic,  it  gives  a  turbidity.  With  silver 
nitrate,  the  supernatant  liquid  is  at  once  colored  yellow,  and 
at  surface  of  contact  a  reduction  of  the  silver  can  be  observed. 
The  same  results  are  obtained  with  ammoniacal  nitrate  of  sil- 


EXPERIMENTAL    STUDY.  327 

ver,  with  additional  formation  of  a  turbidity,  which  is  not  sol- 
uble in  nitric  acid. 

The  reactions  of  this  sample,  as  well  as  those  obtained  with 
Nos,  1,  4,  6  and  7,  demonstrate  conclusively  their  entire  unfit- 
ness for  the  purposes  of  inhalation. 

An  Experimental  Study  of  Anaesthetics.* 

The  author  introduced  his  subject,  by  stating  that  it  was  the 
aim  of  his  paper  to  show,  by  experiments  on  rabbits  and  dogs, 
the  physiological  action  and  relative  safety  of  those  ansesthet- 
ics,  which  are  most  frequently  used  by  surgeons.  The  anaes- 
thetics employed,  were  chloroform,  sulphuric  ether,  bromide  of 
ethyl,  and  various  mixtures  of  these  drugs. 

The  observations  in  these  experiments  were  chiefly  limited 
to  the  temperature,  pulsations,  respirations,  mortality,  and  post- 
mortem appearances  ;  but  the  conclusions  reached,  through  the 
experimental  investigations  made  by  Dr.  H.  C.  Wood,  of  Phil- 
adelphia, for  the  purpose  of  determining  the  physiological 
action  of  chloroform,  sulphuric  ether,  and  bromide  of  ethyl,  on 
the  heart,  are  likewise  mentioned. 

The  introduction  to  this  article  was  followed  by  a  brief  ex- 
planation of  these  experiments,  which  was  intended  to  prepare 
the  reader  for  a  full  comprehension  of  the  work  performed, 
and  which  was  connected  with  the  anaesthetizing  of  eighty-two 
rabbits,  and  twenty-five  dogs.  Following  these  explanatory 
notes,  there  were  presented  in  a  tabulated  form  the  general 
results,  which  are  contained  in  ten  tables,  six  of  which  relate 
to  the  experiments  performed  on  rabbits,  and  four  to  those  on 
dogs. 

The  tables  are  followed  by  a  comprehensive  resume  of  the 
results,  and  the  author  remarks  that  their  most  casual  inspec- 
tion cannot  fail  to  impress  the  observer,  with  the  relatively 
small  mortality  produced  by  the  sulphuric  ether,  when  it  is 
compared  with  that  which  followed  the  use  of  the  bromide  of 
ethyl,  chloroform,  or  the  mixtures  which  were  employed. 

The  percentage  of  the  mortality  produced  by  the  diflferent 

*  Dr.  B.  A.  Watson,  of  Jersey  City. 


328  ARTIFICIAL   ANESTHESIA. 

anfCithetics  employed  in  the  experiineuts  on  rabbits,  was  as 
follows : 

Sulphuric  ether, 16| 

Chloroform, 62^ 

Bromide  of  ethyl, 50 

Alcohol,  chloroform,  and  elher  mixture,  .,••,..  75 
Alcohol,  chloroform,  and  ethyl  mixture, 66f 

Attention  is  called  to  the  fact  that  owing  to  the  evanescent 
character  of  the  bromide  of  ethyl,  it  was  found  impracticable 
to  keep  the  rabbits  constantly  under  the  influence  of  this  drug, 
or  its  mixtures ;  and  consequently,  the  figures  given  in  the 
above,  do  not  accurately  represent  the  mortality  which  may 
justly  be  anticipated,  when  these  animals  are  kept  under  its 
full  influence,  for  two  hours— the  period  during  which  full 
anaesthesia  was  intended  to  be  continued,  in  all  of  the  experi- 
ments. The  above  comments  are  entirely  limited  to  the  ad- 
ministration of  the  bromide  of  ethyl,  and  its  mixtures,  to  the 
rabbits,  the  same,  not  applying  in  any  degree  to  the  dogs,  or  to 
any  other  anaesthetic.  The  whole  number  of  dogs  experi- 
mented on  was  twenty-five,  and  among  these,  twelve  deaths 
occurred,  in  which  the  percentage  of  mortality  chargeable  to 
the  diflerent  anesthetics,  was  as  follows: 

Sulphuric  ether, 00 

Chloroform, 00 

Alcohol,  chloroform  and  ether  mixture, 80 

Alcohol,  chloroform  and  ethyl  mixture, 80 

Bromide  of  ethyl, 100.00 

It  is  shown  by  the  above  comments,  and  others  which  follow 
in  the  author's  detailed  statements,  that  the  danger  arising 
from  the  use  of  the  bromide  of  ethyl  and  its  mixture,  is  more 
accurately  portrayed  in  the  experiments  on  dogs,  than  in  those 
on  rabbits.  The  author  finally  reaches  the  conclusion  that  the 
primary  effect  of  the  bromide  of  ethyl,  resembles  that  of  chloroform, 
and  not  that  of  ether  ;  but  it  is  certainly  much  more  dangerous 
than  the  former  agent,  especially  when  full  anaesthesia  is  con- 
tinued with  it   for  a  period  of  two  hours.     The  deaths  which 


DE.  Watson's  expeeiments.  329 

occurred  ia  the  experiments,  during  the  administration  of  the 
ethyl,  are  believed  to  have  been  caused  by  its  paralyzing  action 
on  the  heart,  while  those  occurring  at  a  later  period  were  prob- 
ably more  or  less  dependent  on  the  same ;  but  in  these  cases, 
the  post-mortem  appearances  reveal  extreme  congestion  of  the 
principal  visceral  organs,  with  other  indications  of  inflam- 
mation, in  all  cases  in  which  death  was  sufficiently  delayed. 

We  have  now  reached  a  point  in  our  study  of  the  various 
anaesthetics,  where  we  believe  we  are  justified  infirmly  asserting, 
in  the  light  of  the  theoretical  and  practical  knowledge,  which 
we  now  possess  of  the  action  of  the  bromide  of  ethyl,  that 
neither  this  drug,  nor  its  mixture,  should  ever  be  employed  for 
the  production  of  ansesthesia,  especially  where  it  is  necessary  to 
prolong  this  state.  It  has  long  since  been  sufficiently  shown, 
that  sulphuric  ether  is  decidedly  the  safest  anaesthetic  which 
has  yet  been  employed  in  general  surgical  practice ;  and  our 
experiments,  are  merely  confirmatory  of  the  correctness  of  this 
decision.  The  use  of  a  mixture  of  alcohol,  chloroform,  and 
ether,  for  the  purpose  of  producing  anaesthesia,  is  theoretically 
wrong  and  practically  bad,  since  it  is  unquestionably  much  more 
dangerous  than  sulphuric  ether. 

By  a  careful  analysis  of  this  valuable  paper  we  find  the  fol- 
lowing points  for  criticism : 

1st.  Other  animals  should  have  been  employed  as  a  compari- 
son with  dogs,  as  it  is  well  known  from  our  experiments,  and 
those  of  others,  that  there  is  considerable  difference  in  the  ac- 
tion of  chloroform  on  dogs,  pigs,  rabbits  or  guinea  pigs. 

2d.  The  chloroform,  and  bromide  of  ethyl,  should  have  been 
chemically  pure  and  from  a  reliable  house,  and  even  what  was 
employed  should  have  been  tested  before  use.  Forty  of  the 
dogs  were  not  suitable  cases  for  the  experiments,  as  they  were 
suffering  from  complicated  traumatic  injuries,  not  stated. 

Dr.  W.  W.  Dawson,  of  Cincinnati,  in  opening  the  discussion, 
said,  that  he  believed  the  sentiment  of  Dr.  Watson's  paper  was 
correct.  He  had  had  a  rather  painful  experience  with  chloro- 
form, and  narrated  two  cases  which  had  terminated  fatally. 
The  first  was  in  1868,  before  the  agent  was  considered  danger- 
ous.  He  was  amputating  a  foot.   The  field  of  operation  became 


330  ARTIFICIAL   ANAESTHESIA. 

bloodless ;  artificial  respiration  was  practiced  without  success. 
At  that  time,  he  said,  we  were  unwilling  to  admit  that  chloro- 
form could  kill,  it  was  so  prompt  in  its  action.  The  second 
case  lost,  was  that  of  a  little  boy.  In  that  case,  also,  the  first 
symptom  was  the  cessation  of  hemorrhage,  from  the  field  of 
operation.  The  anresthetic  was  for  a  moment  withdrawn.  The 
patient  I'evived,  and  the  operation  was  proceeded  with.  Soon 
the  operation  again  became  bloodless,  and  the  same  thing 
occurred  a  third  time.  This  time  it  was  permanent.  The 
heart  had  ceased  to  beat,  and  failed  to  start  even  after  the 
most  energetic  artificial  respiration. 

The  speaker  further  stated,  that  since  this  experience,  he  was 
very  cautious  in  the  use  of  the  alcohol,  chloroform,  and  ether 
mixture,  and  preferred  ether  alone.  He  further  reported  the 
case  of  a  woman  who,  although  she  had  several  times  taken  chlo- 
roform during  parturition,  and  at  onetime  had  remained  under 
its  influence  for  an  hour,  died  after  a  few  inhalations  in  a  den- 
tist's chair. 

President  Moore,  called  attention  to  the  fact,  that  the  woman 
just  spoken  of  was  in  all  probability  in  an  erect  posture  when 
inhaling  the  ether,  a  position  which  renders  the  dagger  much 
greater. 

Dr.  Donald  Maclean,  of  Detroit,  spoke  strongly  in  favor  of 
chloroform.  He  did  not  believe  the  dangers  from  its  use  much, 
if  any,  greater  than  those  from  ether.  He  has  used  it  almost 
exclusively  in  his  practice.  A  great  deal  of  the  danger,  he 
believed,  is  in  the  mental  impression  made  by  using  the  ana8s- 
thetic.  Other  cases,  too,  die  from  other  causes  than  the  action 
of  the  ansesihetic.  In  this  connection  he  reported  the. case  of 
a  woman  whom  he  saw  a  week  ago.  She  was  a  robust  woman, 
apparently  in  perfect  health,  except  a  slight  at^thmatic  dyspnoea, 
a  common  affection  in  Michigan.  He  decided  to  operate  in  a 
few  days,  for  an  ovarian  tumor.  He  had  been  away  only  an 
hour  when  she  died.  Had  the  operation  been  in  progress,  or 
had  the  patient  taken  a  breath  or  two  of  chloroform,  her  death 
would  have  been  attributed  to  it.  He  had  never  seen  death 
from  an  anaesthetic,  and  had  had  trouble  in  only  very  few. 
The  last  case,  in  which  there  was  any  cause  for  alarm,  was  that 


DISCUSSION  OF  Watson's  paper.  331 

of  a  man,  from  whom  he  had  just  removed  the  entire  tongue. 
The  instrument  not  working  perfectly,  there  was  some  hemor- 
rhage. Blood  was  drawn  into  the  larynx,  but  after  removing 
the  blood,  and  practicing  a  little  artificial  respiration,  all  came 
right.  In  conclusion,  he  stated,  that  while  he  believed  in 
the  use  of  chloroform,  he  believed  it  equally  important,  that  the 
agent  be  administered  by  a  competent  person,  able  to  recog- 
nize and  handle  any  complications  that  may  arise. 

Dr.  William  A.  Byrd,  of  Quincy.  111.,  took  his  stand  with 
those  who  opposed  the  use  of  chloroform.  He  had  lost  but  one 
case,  and  that  a  woman,  who  had  been  operated  upon  several 
times  before  coming  under  his  care  for  a  vesico-vaginal  fistula ; 
being  once  nine  hours  anaesthetized.  He  had  also  kept  her 
under  chloroform  for  an  hour,  without  any  symptoms  of  danger, 
and  the  fistula  was  closed.  When,  however,  he  went  to  remove 
the  stitches,  the  patient  demanded  an  anaesthetic.  She  took 
only  a  few  inhalations,  when  she  suddenly  died.  He  further 
spoke  extensively  of  the  action  of  the  bromide  of  ethyl.  He 
had  at  first  used  it  with  the  fullest  confidence,  but  had  aban- 
doned its  use  later,  on  account  of  its  action  being  so  profound 
and  causing  such  marked  suffusion  of  the  face.  He  now  uses 
a  mixture  containing  one  ounce  of  ethyl  bromide,  three  ounces 
of  ether,  and  two  ounces  of  alcohol.  The  action  of  this,  he 
said,  is  prompt,  efiicient,  and,  as  far  as  his  experience  goes, 
safe. 

Dr.  L.  McLane  Tiffany,  of  Baltimore,  said  that  he  must  neg- 
ative absolutely,  the  statement  of  the  essayist,  in  regard  to  the 
similarity  of  action,  between  the  bromide  of  ethyl  and  chloro- 
form. Clinically,  the  action  is  different.  He  had  never  had  a 
fatal  case  due  to  chloroform,  although  he  had  seen  patients  in 
great  danger.  No  one,  he  believed,  could  use  it  with  per- 
fect confidence  ;  and  he  referred  to  the  experience  of  the  late 
Dr.  Sims,  who,  after  having  most  excellent  results  from  its  use, 
lost  a  case  shortly  before  his  death.  He  referred  to  the  prac- 
tice of  Dr.  Chisholm,  of  Baltimore,  who  uses  the  ethyl  bromide 
in  ophthalmic  operations,  with  no  inconvenience. 

Dr.  P.  S.  Connor,  of  Cincinnati,  stated  that  he  had  used  the 
bromide  of  ethyl  pretty  extensively  in  the  Cincinnati  Hospi- 


332  ARTIFICIAL  ANAESTHESIA. 

tal.  He  had  been  both  surprised,  and  astonished,  at  its  action 
on  the  heart.  He  had  seen  the  pulse  run  up  from  100  to  120, 
during  its  administration.  He  had  never  seen  an  agent  so 
mild  and  efficient  in  its  action,  and  yet  so  profound,  and  ap- 
parently, not  dangerous.  He  did  not  believe  that  any  anaes- 
thetic can  be  called  safe.  It  is  impossible,  he  said,  to  carry 
patients  to  the  border-line  of  life,  without  now  and  then  some 
one  slipping  beyond  that  line.  Such  being  the  case,  he  be- 
lieved it  the  duty  of  the  surgeon  to  employ  the  agent  of  least 
danger. 

Spliyginographic  Tracings  of  Ether,  Ethyl  Bromide, 
and  CliJoroforin. 

The  sphygmographic  tracings,  (see  pp.  215  and  216,  Lyman), 
taken  in  the  Physiological  Laboratory  at  Rush  Medical  College, 
Chicago,  correspond  to,  and  corroborate  those  which  were 
taken  for  us  at  the  Physiological  Laboratory,  of  the  Univer- 
sity of  Pennsylvania.  These  tracings,  prove  to  us  that  there 
is  a  material  difference  in  the  rapidity  of  death  and  overpower- 
ing effects  of  chloroform  over  ether  and  ethyl  bromide.  It  is 
true  that  the  pulse-curves  given  of  ethyl  bromide  exhibit  far 
greater  cardiac  depression  under  its  influence,  than  is  produced 
by  ether;  it  more  resembles  chloroform,  but  not  the  same  evi- 
dences of  syncope,  and  the  animal  can  be  restored  even  on  the 
very  brink  of  the  grave,  which  you  cannot  always  do  with 
chloroform.  So  that  we  still  hold  to  the  first  views  expressed 
in  our  second  edition,  that  ethyl  bromide  is  a  safer  anaesthetic 
than  chloroform,  if  chemically  pure.  In  purchasing  ethyl  bro- 
mide, it  should  be  stated  on  the  label,  or  a  guarantee  obtained 
from  the  manufacturer,  that  it  is  free  from  carbon  bromide 
(CjBJ  and  free  bromine.  If  there  is  fear  that  the  article  ia 
not  pure,  have  your  chemist  mix  it  with  two  per  cent,  of  olive 
oil,  agitating  it  from  time  to  time,  for  twenty-four  hours.  The 
flask  should  then  be  placed  upon  a  water-bath,  and  the  pro- 
gress of  distillation  should  be  conducted  at  a  heat,  which  will 
not  permit  the  temperature  of  the  vapor  in  the  space  above 
the  liquid,  to  rise  above  40°  (104°  F.).  The  product  thus  ob- 
tained, will  be  pure  ethyl  bromide. 


ETHER   INHALERS.  333 

CHAPTER    XIX. 

ETHER   INHALERS. 

The  Cone — Inhalers  of  Hawksley,  Ormsby,  Hearn,  Cheatham,  Lente, 
Allis,  Morgan,  Richardson,  Angrove — An  Improved  Ether  In- 
haler by  Parkinson — Rapid  Anaesthesia  by  Ether,  Miiller,  and 
Corning  Device. 

Some  of  the  inhalers  in  use,  are  made  with  the  object  of  heat- 
ing the  anaesthetic  used,  to  furnish  a  large  evaporating  surface, 
or  to  serve  the  purpose  of  allowing  an  admixture  of  atmos- 
pheric, or  warm  air  with  the  gas  or  liquid,  to  be  inhaled. 

Tlie    Cone. 

The  cone  is  the  chief  form  in  which  ether  is  administered, 
as  an  ansesthetic,  in  the  United  States.  It  is  made  by  folding  a 
starched  towel,  inside  of  which  is  a  newspaper,  into  a  cone 
large  enough  to  go  over  the  mouth  and  nostrils.  The  edges 
are  rounded,  and  the  sides  pinned  together  with  catch-pins. 
In  the  apex  of  this  cone,  is  placed  a  carefully-washed  sponge 
dipped  in  hot  water,  and  squeezed  out  from  time  to  time,  so  as 
to  prevent  freezing  of  the  watery  portions  of  the  ether.  Ether 
is  poured  on  the  sponge,  half  an  ounce  at  a  time,  and  repeated, 
as  found  necessary,  by  removing  the  cone  from  the  patient's 
mouth.  A  very  convenient  cone  has  been  found  in  the  ordi- 
nary stra^  cuff,  in  which  is  fixed  a  sponge,  devised  by  a  den- 
tist of  Hartford. 

Advantages  or  the  Cone  for  the  Inhalation  of 
Ether. — The  advantages  are  :  First,  the  ease  with  v.'hich  they 
are  made  and  removed  from  the  patient's  mouth,  when  there  are 
signs  of  danger ;  second,  the  simple  cone  is  never  employed 
with  a  second  patient,  which  is  a  great  advantage  in  the  way  of 
cleanliness.  All  heavy  or  complicated  inhaling  apparatus,  are 
objectionable,  as  they  are  apt  to  become  unclean,  the  valves  get 
out  of  order  and  the  patient  interfered  with  in  his  movements 
by  the  weight  of  them. 

The  chief  objections  to  the  cone,  and  its  modifications,  are,  by 


334 


ARTIFICIAL   ANAESTHESIA. 


Plate  24. 


allowing  the  undiluted  ether  vapor  to  impinge  upon  the  larynx, 
or  the  sponge  to  become  frozen,  with  wastefulness  of  the  ether. 

Ether  Inhalers — Modifications  of  the  Cone. 

In  1866,  Dr,  Lente,  invented  a  modification  of  the  cone  in- 
haler (see  Plate  27).  He  found  the  air-cushion  a  failure,  and 
substituted  hair  in  the  cushion,  which  retains  its  roundness  so 
as  to  fit  the  face  almost  air-tight. 

A  piece  of  sheet  lint  is  stuffed  into  the  cone,  a  piece  of  wire 
or  w^haleboue  is  slipped  in,  so  as  to  keep  the  lint  in  place  and 
prevent  its  touching  the  face.  The  lint  is  saturated  with  ether, 
and  placed  over  the  face.  There  is  an  opening,  fitted  with  a  cork 
stopper  at  the  apex,  large  enough  to  admit  air.  This  is  usually 
closed,  but  if  it  is  found  necessary,  the  stopper  can  be  removed. 
The  ether  can  be  poured  in  at  this  opening,  without  removing 

the  apparatus  from  the  pa- 
tient's face.  Its  cleanliness 
is  perfect,  if  a  different  piece 
of  lint  is  employed  each 
time. 

One  of  the  same  kind  as 
the  above  is  that  called  af- 
ter its  designer,  Dr.  Orms- 
by,  of  Dublin  (Plate  24). 
It  consists  of  a  leather  face- 
piece  with  cushioned  rim, 
provided  with  a  valve, 
which  can  be  opened  at  the 
pleasure  of  the  administra- 
tor ;  at  the  top  of  the  face- 
piece  is  a  cone-shaped  wire 
cage,  covered  externally  with 
leather,  and  leading  into  a 
soft  leather  bag,  covered  by 
a  loose  net,  which  prevents 
its    undue    expansion.      In 

ORMSBY'S  ETHEK  INHALER.  ^j^^    ^^,.^^    ^^^^^    ^    ^p^^^^   -^ 

placed,  and  upon  this,  an  ounce  of  ether  is  poured.     The  ap- 


HAWKSLEY    INHALER.  335 

paratus  is  applied  to  the  patient's  face,  and  he  is  desired  to 
take  a  full  brealh.  Even  when  the  valve  is  kept  widely  open, 
the  sense  of  sufFocation  is  so  great  (the  rush  of  ether  vapor 
producing  more  or  less  spasm),  that  the  patient  struggles 
fiercely  to  escape  what  appears  like  impending  asphyxia. 

Should  it  be  necessary  to  add  fresh  anaesthetic  during  the 
operation,  it  is  done  by  pouring  ether  down  a  tube  which 
enters  the  centre  of  the  sponge. 

Ormsby's  inhaler,  is  open  to  several  objections:  e.g.,  it  pro- 
duces great  discomfort  by  allowing  undiluted  ether  vapor  to 
impinge  upon  the  larynx ;  the  sponge  is  very  liable  to  freeze 
hard,  and  so  no  evaporation  of  ether  takes  place ;  it  occasions 
great  struggling;  it  is  wasteful  of  the  ether. 

Hawksley  Inhaler. 

It  consists  of  "  a  glass  vessel,  capable  of  holding  ten  ounces 
of  ether,  with  an  inlet  valve  for  air,  and  its  slicing  tube  is 
graduated  in  ounces  for  the  purpose  of  measuring  the  quantity 
of  ether  consumed.  A  pipe  conveys  the  vapor  to  the  face-piece, 
the  edge  of  which  is  surrounded  by  a  water-cushion,  to  secure 
exact  adaptation.  There  is  also  a  shutter-valve  for  regulating 
the  admission  of  air,  either  at  the  beginning  of  an  operation,  or 
during  its  course.  It  has  also  an  additional  pipe,  furnished 
with  a  valve,  which  conveys  the  expired  vapor  to  the  floor." 
This  latter  is  a  useful  addition,  when  employed  in  a  hospital, 
where  a  large  number  of  patients  are  to  be  etherized  in  succes- 
sion, so  that  the  ether  is  not  diffused  in  the  air  around  the 
operator.  When  in  use,  the  vessel  in  which  the  ether  is  con- 
tained, is  immersed  in  water,  heated  to  100°,  which  promotes  a 
more  rapid  and  equable  evaporation  of  the  ether.  "  Ether 
boils  at  about  90°  ;  but  before  the  quantity  contained  in  the 
vessel  has  reached  that  point,  the  temperature  of  the  surround- 
ing water  will  have  fallen."  This  is  a  valuable  inhaler ;  it  is  too 
complicated  for  every-day  use  by  the  physician  or  surgeon,  but 
will  be  found  very  useful  in  large  hospitals,  and  cause  a  great 
saving  in  the  amount  of  ether  employed. 

The  most  recent  ether  inhaler,  invented  by  a  man  of  great 
practical  experience,  it  has  two   most  positive  advantages : 


336 


ARTIFICIAL   ANAESTHESIA. 


Plate 


there  is  no  waste  of  ether  or  dififusion  in  the  room  ;  second,  the 
cloth  can  be  removed  and  the  water  pressed  out  of  it,  and  again 
employed,  being  free  from  all  moisture  and  carbonic  acid. 

Heani's  Ether  lulialer. 

It  is  named  after  its  inventor.  Dr.  Joseph  W.  Hearn,  of  this 
city,  who  has  had  an  extended  experience  in  the  administra- 
tion of  ansesthetics. 

The  inhaler,  (Plate  25) 
has  its  outer  case  A, made 
of  thin  sheet  metal,  hav- 
J)  ing  the  lower  edge,  which 
comes  in  contact  with  the 
face,  covered  with  rub- 
ber. 

Inside  of  this  case,  a 
screen  of  wire  gauze  B  is 
fitted,  which  comes  op- 
posite the  lower  joint,  as 
at  A. 

The  lint  or  canton  flan- 
nel upon  which  the  ether 
is  poured  is  shown  at  C, 
and  is  held  in  place  be- 
tween the  wire  gauze 
screen  B,  and  the  funnel- 
shaped  top  D. 

The  object  of  this  in- 
haler is  to  furnish  an 
undiluted  ether  vapor, 
and  prevent,  as  it  should 
■^  when  ether  is  used,  the 
patient's  inhaling  thesur- 
rounding  atmosphere. 
The  time  required  to  pro- 
duce complete  ansesthe- 
sia,  in  ordinary  cases,  is 
from  five  to  eight  minutes. 

"  Another  object  of  the  inhaler  is  economy ;    it  rarely  re- 


CHEATHAM'S   INHALER. 


337 


quiring,  more  than  two  or  three  ounces  of  ether  to  produce  the 
full  effect,  for  which  reason,  it  is  especially  adapted  to  hospital 
use.  The  apparatus,  by  confining  the  ether  vapor,  prevents  in 
a  great  degree  the  impregnation  of  the  atmosphere  in  the 
room."  If  the  patient  needs  air,  the  inhaler  can  be  withdrawn 
between  every  second  or  third  inspiration. 


Cheatham's  Ether  Inhaler. 

This  operates  by  replenishing  the  evaporating  surface,  with- 
out removing  it  from  the  face.  A  patient  cannot  be  etherized 
as  quickly  with  it  as  with  the  common  cone,  but  with  much 
less  ether,  and  by  it,  you  avoid  the  disagreeable  effects  of  hav- 
ing the  ether  permeating  every  part  of  the  office,  or  house,  in 
which  it  is  used.  Its  convenience  of  application  is,  also,  quite 
obvious.  The  ease  with  which  the  face-piece  {being  paper) 
can  be  removed  immmediately  after  use,  and  thrown  away,  is, 
we  think,  a  strong  recommendation  in  its  favor. 

The  apparatus  consists  of  a  tin  cup  (Plate  26,  A)  holding 

Plate  26. 


in  the  in-^ide,  a  sponge  as  an  evaporating  surface,  and  con- 
nected from  the  top  by  rubber  tubing,  with  the  bottle  that 
contains  the  anaesthetic.  This  tube  has  attached  to  its  dis- 
tal end,  a  cap  D,  that  will  fit  over  the  neck  of  almost  any 
bottle,  thus  doing  away  with  Lente's  graduated  bottle. 

Mode  of  using  the  Inhaler. — Make  a  cone  of  paper,  cut  the 
top  off,  so  when  the  tin  cup.  A,  is  slipped  inside  the  top  of  che 
15 


338 


ARTIFICIAL   AN^iESTIIESIA. 


cup  it  will  protrude  a,  line  or  two  from  the  top  of  cone. 
Place  tin  cup,  B,  over  both  cup  and  cone,  screw  it  down 
tightly  by  means  of  nut,  C,  and  you  have  the  cone  held 
tightly.  Attach  tube  to  top  of  cup,  and  the  apparatus  is  com- 
plete. The  smaller  the  cone,  the  more  quickly  you  can  get  the 
patient  under  the  influence  of  the  ana3Sthetic.  We  would  sug- 
gest after  the  cone  is  in  position,  the  bottom  should  be 
trimmed,  leaving  a  part  of  it  (we  shall  call  it  the  back  part) 
that  is  intended  to  go  over  the  chin,  three  inches  longer 
than  the  cup,  and  sloping  forwards  and  upwards,  leaving  the 
front  part,  intended  to  go  over  the  nose,  about  an  inch  longer 
than  cup.     E  gives  an  inside  view  of  cup.  A.* 

Dr.  Licnte's  Etlier  Inlialer. 

As   early  as   1866,  Dr.  Lente   invented  a   form  of  inhaler, 
which  has  recently  been  modified.     (See  Plate  27).     The  pre  s- 
Plate  27.  ent   improved    instrument,    re- 

sembles very  much  the  face- 
piece  of  "  Waldenburg's  ap- 
paratus" for  the  inhalation  of 
tondensed  and  rarefied  air. 
The  idea  of  using  shtet  brass, 
ind  the  india-rubber  air- 
ushion,  Avas  taken  from  it. 
i'he  air-cushion,  however, 
\  roved  a  failure,  and  the  inven- 
tor substituted  hair  for  stuffing 
the  cushion,  which  he  state?, 
retains  sufficient  of  its  rotundity, 
to  fit  the  face  air-tight. 
Mode  or  Employing  this 
formofInhalee. — A  piece  of  sheetlint  is  stuffed  into  the  cone, 
a  piece  of  wire  or  whalebone  is  slipped  in,  so  as  to  keep  the  lint 
in  place  and  prevent  its  touching  the  face.  The  lint  is  satu- 
rated with  ether  and  placed  over  the  face.     There  is  an  open- 

*  These  various  forms  of  inhalers  are  inadn  by  S.  S.  AVhite,  Snowden,  Gcmrig, 
or  Kolbe,  instrument  makers,  of  this  city  ;  also,  George  Tiemann  &  Co.,  of  New 
York,  and  by  Codman  <fe  SburtlefT,  of  Boston. 


ALLIS'   INHALER. 


339 


ing,  fitted  with  a  cork  stopper  at  the  apex,  large  enough  to  ad- 
mit air.  This  is  usually,  closed,  but  if  it  is  found  necessary  the 
stopper  can  be  removed.  The  ether  can  be  poured  in  at  this 
opening,  without  removing  the  apparatus  from  the  patient's 
face.  Its  cleanliness  is  perfect,  as  a  different  piece  of  lint  should 
be  employed  each  time. 

AUis'  Ether  Inhaler. 

We  present  below  cuts  of  the  apparatus  of  Dr.  Allis,  for  the 
Plate  28. — Instrument  complete. 


340 


ARTIFICIAL   ANAESTHESIA. 


administration  of  ether.  This  instrument  has  been  in  use  in 
the  United  States,  and  Europe,  for  several  years,  and  may  be 
said  to  have  won  a  place  among  the  standard  instruments. 

This,  and  the  following  cuts,  are  two-thirds  the  size  of  the 
manufactured  instrument. 

It  is  now  made  simpler  and  stronger  than  the  first  that 
were  offered  to  the  profession. 

Plate  29. 


Description  of  the  Inhaler. — It  consists  of  a  metallic 
frame,  sufficiently  large  to  cover  the  lower  part  of  the  face. 
The  bars  are  nearly  a  quarter  of  an  inch  broad,  leaving  a 
quarter  of  an  inch  between  each  and  its  fellow.  The  spaces 
are  made  by  a  punch,  which  removes  a  section  from  a  solid 
sheet  of  metal.      It  will  thus   be  seen  that  there  can  be  no 


ALLIS'    INHALER. 


341 


danger   of   tlie    bars    giving    way,  as  they  would  were  they 
soldered  upon  a  band. 

In  Plate  30,  we  produce  Plate  29,  with  a   bandage  partly 
laced  between  the  bars.  It  has  been  passed  from  side  to  side,  di- 


Plate  30. 


viding  the  instrument  into  parallel  sections.  On  the  right,  a 
part  of  the  bandage  may  be  seen  rolled  up.  When  the 
bandage  has  been  passed  between  all  the  bars,  and  the  hood 
or  cover  put  on  (Plates  28  and  31),  one  can  look  through  the  in- 
strument from  end  to  end,  as  there  is  a  space  of  nearly  a  quar- 
ter of  an  inch  between  the  several  sections  of  the  bandage. 


342 


ARTIFICIAL   ANESTHESIA. 


The  advantages  of  this  mode  of  construction  are  stated  by 
Dr.  Allis  to  be: — 

Ist.  It  gives  the  patient  (Phite  31),  the  freest  access  of  the  air. 
It  is  necessary  that  the  air  should  be  saturated  with  the  vapor  of 
ether. 

Plate  31. 


SNOWDEN 


2d.  It  affords  a  series  of  thin  surfaces,  upon  which  the 
ether  can  be  poured,  and  from  which  it  will  almost  instantly 
evaporate.  In  this  respect  it  differs  from  the  sponge,  which 
retains  the  ether  in  a  fluid  state  much  longer.  Should  the 
bandage  become  soiled  a  new  one  can  be  inserted  in  a  few 
minutes. 

3d.  By  leaving  the  instrument  open  at  the  top,  the  supply 
can  be  kept  up  constantly  if  desired ;  and  as  ether  vapor  is 
heavier  than  air,  there  is  no  loss  by  not  covering  it.  The  top 
should  never  be  covered. 


ALLIS'    INHALER.  343 

Mode  of  using  the  inhaler : — 

1st.  Place  a  towel  beneath  the  chin  of  the  patient,  as  ex- 
perience has  taught  that  a  towel  should  always  be  within 
reach  in  administering  ansesthetics. 

2d.  Place  the  instrument  over  the  face,  covering  the  nose 
and  chin,  and  let  the  patient  breathe  through  it  before  any 
ether  is  applied.  This  will  convince  him  that  he  is  not  to  be 
deprived  of  air. 

3d.  Begin  with,  literally,  a  few  drops  of  ether ;  this  will  not 
irritate  the  larynx.  Add,  in  a  few  seconds,  a  few  drops  more, 
and  as  soon  as  the  patient  is  tolerant  of  the  vapor,  increase  it 
gradually  to  its  fullest  effect.* 

4th.  When  the  patient  is  fully  influenced,  it  is  well  to  add 
a  few  drops  at  short  intervals,  and  thus  keep  up  a  gradual 
anaesthetic  effect. 

The  advantages  of  the  inhaler: — 

1st.  It  presents  a  large  surface  for  the  liberation  of  ether 
vapor.  The  partitions  are  made  of  thin  bandage,  and  the  air 
coming  to  both  sides  of  each  layer,  sets  the  ether  vapor  free, 
more  rapidly,  than  is  possible  in  the  use  of  a  towel  or  sponge. 

2d.  It  is  open  at  the  top,  and  ether  can  be  added  constantly 
if  desired,  and  in  small  quantities,  without  removing  from  the 
face.  The  sponge  and  towel  both  require  removal,  and  the 
ether  is  usually  poured  on  them  in  quantities, 

3d.  The  ether  vapor  falls  by  its  weight,  as  it  is  heavier  than 
the  air;  and  as  the  instrument  fits  the  face,  the  patient  gets 
the  full  advantage  of  it. 

4th.  It  does  not  cover  the  patient's  eyes,  does  not  terrify 
him,  and  he  often  passes  under  its  influence  without  a  struggle. 

6th.  By  its  proper  use,  the  laryngeal  irritation  may  be 
wholly  avoided,  the  anaesthetic  effect  as  easily  gained  as  is 
possible,  with  the  use  of  ether,  a  great  economy  of  ether,  and 
great  comfort  to  the  patient. 

Dr.  G.  H.  Coburn,  a  resident  physician  of  Howard  Hos- 
pital, carefully  recorded  all  the  cases,  at  our  request,  occurring 

*Whea  the  effect  of  the  anEesthetic  is  apparent,  a  siagle  layer  of  a  coarse  towel 
may  be  laid  over  the  nose  and  mouth,  and  the  iajtrnment  replaced.  This  is  a  wise 
precaution  against  vomiting,  or  spitting. 


344  ARTIFICIAL   ANAESTHESIA. 

during  the  years  1875-76,  in  which  this  form  ot  Allis'  inhaler 
was  employed  in  the  various  surgical  operations,  performed  in 
the  institution.  It  was  found  by  him  that  the  shortest  time 
required  to  produce  complete  ana?sthesia  in  a  young  female 
patient,  was  three  minutes,  and  the  amount  of  ether  employed, 
was  only  one  fluid  ounce  The  longest  period  required  in  an 
adult  female  was  seven  minutes,  and  the  amount  of  ether  used, 
two  ounces  and  a  half.  The  doctor  did  not  notice,  in  any  of 
the  cases,  but  slight  redness  of  the  eyes.  In  a  few  inptances, 
there  was  a  hysterical  tendency,  among  the  females.  If  solid 
food  had  been  taken,  vomiting  would  follow,  but  after  liquid, 
or  light  forms  of  nourishment,  vomiting  was  very  rare,  not 
more  than  one  in  fifty  cases.  In  temperate  males  the  time  for 
full  anaesthesia  was  from  five  and  a  half  to  eight  minutes. 
Ether  consumed  :  minimum  quantity,  two  ounces;  maximum, 
three  ounces. 

The  objections  to  this  form  of  apparatus  are : — 
Ist.  That  the  exhaled  vapor  is  not  conveyed  to  the  floor, 
but  is  diffused  in  the  air,  to  be  breathed  by  the  operator,  and 
his  assistants.  For  a  single  operation,  this  is  not  of  much 
importance,  but  where  there  are  a  number  of  cases,  the  ar- 
rangement is  not  conducive  to  the  comfort  of  the  operator. 

2d.  The  bandage  of  muslin  across  the  bottom  becomes 
clogged  with  moisture  and  saliva,  and  at  times  by  discharges 
from  the  stomach,  and  cannot  be  so  readily  removed. 

3d.  Owing  to  the  peculiar  arrangement  of  the  muslin  strips, 
it  is  tedious,  when  it  is  required  for  a  number  of  patients,  to  re- 
move or  replace  them. 

In  a  conversation  with  Dr.  Allis,  he  stated,  that  he  considered 
the  chief  merit  of  his  instrument  was,  that  it  thoroughly  and 
instantaneously  liberated  the  ether,  and  that  while  there  was 
not  the  least  impediment  to  respiration,  yet  all  the  air  was  im- 
pregnated with  the  ansesthetic. 

Neither  ether,  nor  chloroform,  can  be  inhaled  in  the  pure 
state. 

It  is  always  atmospheric  air,  impregnated  with  the  anaes- 
thetic, that  sustains  life  and  produces  anjesthesia. 

The  expression  "  give  him  nothing  but  ether,  exclude  the 


ALLIS'   INHALER.  345 

air,"  are  ouly  relative  terms;  they  simply  mean  saturate  the 
air,  as  muoh  as  possible  with  the  ether.  Permit  the  pacietiL  to 
have  no  fresh  air,  but  compel  him  to  breathe  air,  charged  with 
ether. 

Now,  ia  Allis'  apparatus,  there  is  no  chance  for  the  ether  to 
remain  in  its  fluid  state,  but  exposed  as  it  is  on  a  thin  stratum 
of  muslin,  it  yields  its  anaesthetic  principle  promptly. 

When  he  first  employed  his  instrument,  bystanders  would 
suggest  that  it  be  closed  at  the  top,  so  as  to  permit  no  escape  of 
ether. 

This  win  show  that  the  true  laws  of  ether  were  overlooked  ; 
ether  vapor,  while  it  will  diffuse  itself  throughout  an  entire 
room,  is  of  greater  specific  gravity  than  atmospheric  air,  and 
tends  to  the  floor. 

To  close  this  apparatus  at  the  top,  would  necessitate  ingress 
of  air  at  the  part  surrounding  the  mouth,  for  air  must  be  ad- 
mitred. 

If  it  be  excluded  at  the  bottom  and  left  open  at  the  top,  the 
advantage  of  having  a  constant  supply  of  ether  dropping  upon 
the  folds,  is  very  great. 

As  germane  to  this  subject,  we  would  direct  attention  to  the 
following  experience,  recorded  by  Dr.  Wm.  Goodell,  of  Phila- 
delphia, in  the  course  of  a  recent  paper,  giving  a  year's  ex- 
perience in  ovariotomy : 

"Oae  of  the  chief  lessons  I  have  learned  from  my  experience 
during  the  past  year,  is  to  administer  ether.  Hitherto  I  have,  in 
common  with  most  American  snrgeoas,  given  this  anaesthetic  by  a 
closed  cone,  in  such  a  manner  that  the  patient  breathed  her  own  air 
over  and  over  again.  I  am  now  disposed  to  think  that  this  is  a  very 
unsafe  mode,  and  that  to  it  is  due,  in  a  large  measure,  the  alarming 
prostration  of  the  patient  while  undergoing  the  operation.  For  in- 
stance, among  the  tweaty-five  cases  of  last  year,  cases  70,  71,  and  82 
presented  such  profound  symptoms  of  shock,  that  the  operation  had 
to  be  suspended,  until  hypodermic  injections  of  brandy,  and  of  ether, 
were  made,  and  some  degree  of  reaction  had  set  in.  In  cases  70,  and 
71,  it  was  indeed  with  great  difficulty  that  the  women  were  kept 
from  dying  on  the  table ;  while  case  85,  clearly  died  from  oedema  of 
the  lungs.     Now,  I  do  not  find  such  alarming  symptoms  referred  to, 

15* 


346 


ARTIFICIAL   ANiESTHESIA. 


in  any  reports  of  cases,  by  British  opei-ators.  I  am  therefore  forced 
to  the  conclusion,  that  either  under  the  strain  of  rivalry,  they  do  not 
operate  in  very  desperate  cases,  or  iheir  mode  of  administering 
anaesthetics,  is  a  safer  one  than  ours.  Fully  impressed  with  this 
idea,  I  have  lately  been  using  Dr.  Allis'  improved  inhaler,  and 
have  thus  far  found  it  to  act  promptly,  safely  and  economically." 

A  Folding  Allis*  Ether  Inlialer. 

"  Although  many  surgeons  still  prefer  the  ordinary  folded 
napkin,  or  improvised  cone  method  of  administering  ether,  yet 
there  can  be  no  doubt  as  to  the  advantages  to  be  derived  from 
the  use  of  a  specially  devised  apparatus,  like  the  Allis'  Inhaler. 
In  it,  are  combined  simplicity  of  construction,  ease  of  manipu- 
lation, rapidity  of  etherization,  economy  of  ether  and  a  free 
ingress  of  atmospheric  air  charged  with  ether,  and  egress  of 
expired  air.  It  is  open  to  the  objection,  though  to  a  less  extent 
than  other  instruments  of  its  class,  of  being  somewhat  cumber- 
some when  carried  about,  and  of  occupying,  therefore,  consid- 

Plate  32. 


erable  space  in  the  operating  satchel.    My  attention  was  forci- 
bly directed  to  this  point,*  when  devising  an  emergency  operating 

*  By  George  K.  Fowler,  M.D.,  Boooklyn,  N.  Y. 


ALLI8'    INHALER. 


347 


bag,  recently.  I  have,  therefore,  endeavored  to  overcome  this 
objectionable  feature  by  slightly  altering  the  shape  of  the  in- 
haler, in  such  a  manner,  as  to  allow  of  its  being  folded  flatwise. 
The  accompanying  cuts,  will  show  how  this  is  accomplished. 
Plate  32,  represents  the  inhaler  folded,  ready  for  placing  in  the 
pocket  or  satchel,  in  which  shape  it  occupies  about  as  much 
room  in  the  pocket  or  satchel  as  an  ordinary  visiting  list.  By 
a  very  simple  movement,  provided  for  by  bringing  together  the 

Plate  33. 


corners  of  the  metal  sides,  the  two  long  sides  are  made  to  sepa- 
rate from  each  other,  until  the  shape  shown  by  Plate  33  is 
formed,  in  which  position  it  is  securely  held,  by  a  little  bar, 
which  swings  over  from  one  corner,  to  the  one  diagonally  oppo- 
site, and  fastened,  by  its  bent  extremity,  into  a  socket  provided 
for  the  purpose.  The  only  covering  needed  for  an  Aliis'  In- 
haler, is  a  simple  towel  folded  lengthwise,  in  which  the  instru- 
ment is  inclosed,  just  prior  to  its  use.  This  can  be  procured  at 
the  patient's  house,  and,  after  the  operation,  unpinned  and 
thrown  aside." 
Mr.  Morgan,  Surgical  Registrar  at  St.  George's  Hospital, 


348  ARTIFICIAL   AN.^ESTHESIA. 

London,  has  suggested  a  modification  of  the  felt  cone  ordi- 
narily in  use  in  this,  and  other  hospitals,  in  England. 

"  The  instrument  consists  of  a  cone  of  felt,  in  the  apex  of 
which  a  piece  of  sponge  is  fixed,  on  which  the  ether  is 
poured.  This  is  fitted  into  a  case  of  metal,  surrounded  by  an 
outer  one  of  similar  shape,  but  sufBciently  large  to  leave  a 
space  between  them,  through  which  the  expired  air  can  freely 
circulate  before  it  escapes.  There  are  two  valves,  acting  in 
opposite  directions — one  admitting  the  air,  which  passes 
through  the  sponge  moistened  with  ether ;  the  other,  through 
which  it  escapes  into  the  chamber  between  the  two  metal 
cones.  The  close  application  of  the  instrument  to  the  face,  is 
secured  by  means  of  the  India-rubber  cushion,  which  is  filled 
with  air  by  the  tap,  so  that  all  the  air  inspired,  must  pass 
through  the  valve.  The  warmth  produced  by  the  air  which 
circulates  between  the  two  cones  prevents  the  ether  on  the 
sponge  from  freezing,  and  the  vapor  which  escapes  is  carried 
off  by  a  tube  to  any  distance  which  may  be  desired.  The 
quantity  of  ether  required  in  this  apparatus  is  much  smaller 
than  in  the  ordinary  cone;  and  the  advantage  it  thus  pos- 
sesses, as  well  as  the  safety  and  freedom  from  ether  vapor  ob- 
tained by  the  administrator,  render  it  superior  to  other  similar 
apparatus.  Several  American  surgeons,  whose  knowledge  and 
experience  of  ether  are  generally  recognized,  have  expressed 
considerable  approbation  of  this  invention.  It  is  manufac- 
tured and  sold  by  Messrs.  Blaise  &  Co.,  67  St.  James  Street." 

The  following  results*  were  obtained  by  the  use  of  Morgan's 
inhaler : 

REPORT   OF   EXPERIMENTS   WITH   ETHER   IN   TWENTY -SIX 
CASES. t 
Shortest  time  taken    to  place  a  patient  under 

the  anaesthetic  influence, 3  min.  30  seconds. 

Longest  lime, 24  "  0        " 

Average  tinre, 8  "  10        " 

Average  time  under  influence, 19  "  6        " 

*  Those  who  liave  used  both  tlie  English  anJ  American  ethers,  state,  that  the 
former  gives  less  favorable  results  than  our  washed  ether,  a;ther  fortior,  U.  S.  P. 

fBy  Surgeon-Major  Porter,  Assistant  Professor  of  Military  Surgery.  London  ; 
1875. 


Richardson's  inhaler.  349 

Smallest  quantity  of  ether  used  in  one  case,    .      2  ounces  4  dracLms. 

Largest, 9      " 

Average, 5      "       1        " 

Vomiting,  occurred  in  eleveu  cases,  during  or  after  the  ad- 
ministration of  the  drug.  Excitement  occurred  in  seven  cases 
to  a  marked  degree,  during,  or  after  administration,  of  the  drug. 
(Does  our  experimenter  mean  resistance  as  excitement,  or,  if  in 
a  female,  as  hysterical  excitement?)  The  anaesthetic  was 
invariably  given  on  an  empty  stomach.  The  ether  was  given 
by  Morgan's  inhaler.  Ether  was  analyzed  and  found  to  be 
perfectly  pure,  s.  g.  720.2  at  64°  F. 

Ether  Inhaler  of  Dr.  Richardson. 

In  1873  Dr.  B.  Willis  Richardson,*  of  Dublin,  designed  and 
employed  a  simple  form  of  ether  inhaler,  for  use  in  hospital 
practice.  The  ether-box,  of  metal,  has  a  capacity  °of  three 
ounces,  with  an  oval  air-opening  half  an  inch  long,  and  about 
an  eighth  of  an  inch,  from  its  upper  margin.  By  rotating  the 
lid,  which  has  a  similar-shaped  opening  in  its  side,  the  admis- 
sion of  air  can  be  easily  regulated.  At  the  beginning  of  the 
inhalation,  the  inner  opening  may  be  fully  exposed,  and  gradu- 
ally covered.  The  ether-box  communicates  with  the  face- 
piece  by  means  of  a  tube  an  inch  in  length,  and  one  inch  and 
a  half  in  diameter,  the  ether-box  opening  of  the  tube  being 
two-thirds  closed  by  a  fixed  diaphragm.  This  prevents  the 
fluid  ether  from  passing  into  the  tube,  when  the  patient  is  in 
the  horizontal  position.  The  face-piece  opening  of  the  tube, 
has  a  diameter  of  one  inch.  The  tube  itself,  in  order  to  in- 
crease the  evaporating  surface,  should  be  nearly  filled  with 
soft  cotton  candlewick,  having,  when  used,  one  end  submerged 
in  the  fluid  ether.  The  inhaler  may  be  made  of  silvered 
copper,  or  of  block  tin,  but  the  margin  of  face-piece,  should  be 
formed  of  flexible  metal,  and  covered  with  morocco  leather. 

"  This  inhaler,  the  inventor  states,  to  be  simple  in  form,  and 
moderate  in  price,  and  designed  as  a  substitute  for  the  towel 

*  Description  and  illustration  of  an  ether  inhaler,  etc.     By  B.  W.  Richardson, 
F.R.C.S.I.    John  Falconer,  Dublin,  1873. 


350  ARTIFICIAL   ANESTHESIA. 

and  sponge,  in  the  use  of  which,  there  is  much  waste  of  ether, 
a  matter  in  hospital  economy,  that  may  be  of  some  importance." 
Dr.  Richardson  has  employed,  and  prefers,  anhydrous  sul- 
phuric ether,  because  it  was  found  to  produce  the  most  rapid 
anaesthesia. 

r>r.  Angrove's  Handy  Ether  Inhaler.* 

This  gentleman  states,  that  in  England,  there  is  a  great  want 
felt,  just  at  present,  for  an  effective,  handy,  and  cheap,  inhaler. 
He  has  endeavored  to  supply  this  want.  His  inhaler  "consists 
of  a  cylinder,  on  which  fits,  by  a  bayonet  joint,  a  cap,  around 
the  rim  of  which,  are  attached  several  stout  wires.  The  top  of 
the  cap  is  perforated  with  holes,  and  through  the  middle  is 
inserted  a  long  metal  tube  reaching  nearly  to  the  bottom  of 
the  cylinder.  One  end  of  an  air-tight  silk  reservoir  is  fastened 
to  the  cap,  and  the  other  to  the  flexible  tube,  which  is  also 
attached  to  the  mouth-piece.  The  flexible  tube  runs  through 
the  reservoir,  and  is  directly  connected  with  the  metal  tube. 
The  inside  of  the  cylinder,  is  lined  with  felt,  and  a  couple  of 
turns  of  the  same  material,  are  wound  around  the  wires,  thus 
presenting  three  surfaces  for  the  evaporation  of  the  ether. 
Having  filled  the  reservoir  with  air,  an  ounce  of  ether  is 
poured  into  the  cylinder  through  the  nozzle;  this  diff'uses 
itself  all  over  the  felt.  The  mouth-piece  is  then  applied  to 
the  patient ;  he  is  told  to  '  draw  in  his  breath  ; '  the  vapor  he 
inspires  comes  from  the  reservoir,  passes  through  the  holes  in 
the  cap,  over  the  evaporating  surfaces  of  felt,  and  up  through 
the  whole  length  of  tube;  he  expires  the  same  vapor,  which 
passes  back  to  the  reservoir,  and  becomes  re-charged  with 
ether  during  the  next  inspiration.  The  inventor  further  states, 
he  has  completely  ancesthetized  several  individual  patients,  in 
a  little  over  one  minute,  one  in  forty  seconds.  An  ounce  of 
ether,  is  sufiicient  to  keep  a  patient  about  ten  minutes." 

The  cylinder  is  five  inches  high  and  three  in  diameter.  The 
reservoir  holds  about  a  pint  and  a  half.     The  length  of  the 

*The  description  of  a  handy  ether  inhaler.  By  W.  T.  Angrove,  House  Surgeon 
to  the  Yaniijuth  Hospital      London  Lancet,  March,  1877,  p.  123. 


IMPROVED   INHALER. 


551 


tube  can  be  made  according  to  taste.  To  show  that  they  are 
still  at  sea  in  England,  in  regard  to  ether  inhalers,  we  will  con- 
clude this  part  of  our  subject  by  giving  a  description  of  one  of 
the  latest  invented,  from  the  British  Medical  Journal. 

An  Improved  Ether  Inhaler.* 

"In  presenting  this  apparatus  to  the  notice  of  the  profession, 
I  wished  at  the  outset  to  disclaim  any  idea  of  misappropriation. 
The  instrument  is  in  principle,  identical  with  Ormsby's  inhaler, 
the  best  points  of  which  have  been  utilized.  A  practical 
experience  of  some  nine  years,  with  the  original  apparatus,  has 
induced  me  to  modify  it,  so  that  a  compact,  efficient  and  in- 
expensive inhaler  could  be  obtained  by  any  practitioner.  The 
improvements  are  the  substitution  of  rigid,  instead  of  flexible 
metal  in  the  face-piece,  the  omission  of  the  ether  supply  tubes, 
and  the  modification  of  minor  details  throughout. 

"  The  apparatus  consists  of  a  metallic  face-piece,  the  base  of 
which  corresponds  to  the  usual  facial  lines.    To  the  upper  part 


A.  Inhaler  ready  for  use.  B.  Ether  reservoir.  C.  Ether  measure,  showing  sponge 
inside.  1.  Air  cushion,  inflated.  2.  Air  cap.  3.  Wire  net  basket  to  contain 
sponge.    4.  Kubber  bag  collapsed. 

of  this  is  fastened  a  wire  net  basket,  around  the  mouth  of  which, 
and  projecting  into  the  face-piece,  is  a  small  gutter,  which  pre- 
vents ether,  or  moisture,  from  dropping  on  the  patient.    On  one 

*By  James  H.  Parkinson,  L.R.C.S.I. 


352  ARTIFICIAL   AN.^STHESIA. 

side  of  the  face-piece  is  aa  air  cap,  which  exposes  or  covers  a 
slot,  ou  rotation.  A  collapsible  rubber  bag,  shaped  somewhat 
like  a  cranial  ice  cap,  is  attached  to  the  face-piece,  its  elastic 
neck  grasping  the  apex  of  the  latter,  where  a  groove  has  been 
made  for  its  reception.  A  rubber  air  cushion  fits  over  the  base 
of  the  face-piece,  maintaining  its  position  by  a  lip  which  forms 
part  of  the  cushion. 

"  To  prepare  the  inhaler  for  use,  when  the  temperature  of  the 
room  is  below  65°,  place  a  small  napkin  or  towel,  wrung  out 
of  very  hot  water,  in  the  face-piece  for  a  few  minutes.  The 
sponge,  which  should  have  an  absorption  capacity  of  two 
ounces,  is  soaked,  squeezed  dry,  and  placed  in  the  wire  net 
cone,  so  that  every  part  is  above  the  gutter.  The  air  cushion 
is  then  fitted,  and  partially  inflated.  Pour  one  ounce,  by 
measure,  of  Squibb's  ether  on  the  sponge,  and  place  the  inhaler 
on  the  face,  with  the  air  slot  wide  open.  This  should  be 
closed  after  three  or  four  inspirations.  During  the  progress  of 
an  operation,  fresh  ether  is  added,  as  required,  iu  quantities  of 
four  drachms.  If  used  for  half  an  hour,  it  is  advisable  to 
remove  the  sponge  and  squeeze  out  the  moisture  which  has 
formed  by  condensation. 

"The  points  of  superiority  claimed  for  this  inhaler  are,  that  it 
is  compact,  portable  and  inexpensive.  It  is  simple  in  con- 
struction, and  the  rubber  portions,  when  worn  out,  are  easily 
duplicated.  It  is  most  economical  in  the  use  of  ether,  and  the 
unpleasant  odor  of  the  drug  by  diflFusion,  is  absent.  With  it, 
the  production  of  anaesthesia,  is  a  certainty.  The  rapidity  of 
its  action  will  equal  any  apparatus,  and  there  is  no  method  of 
ether  administration,  which  surpasses  it,  in  safety. 

"  Amongst  the  objections  raised,  are  those  common  to  all 
permanent  apparati :  that  it  is  dirty,  and  that  infective  matter 
will  adhere  to  it,  or  may  lodge  in  the  sponge.  The  simplicity 
of  its  construction  admits  of  a  ready  and  perfect  cleansing; 
and  no  part  will  be  injured  by  hot  water  or  antiseptic  solutions 
which  are  familiar  to  most  practitioners.  Against  the  inhaler 
per  se  it  is  urged  that  the  anaesthesia  parlakes  largely  of  car- 
bonic di-oxide  poisoning — that  this  is  a  source  of  danger,  and 
an  inseparable  defect. 


IMPEOVED   INHALER.  353 

"The  re-breathing  of  the  ether-charged  air  with  a  small  at- 
mospheric mixture  is  the  main  point  on  which  the  superiority 
of  the  inhaler  rests.  That  it  is  not  in  any  sense  a  defect  or 
danger,  practical  experience  of  several  years  has  proved;  and, 
in  support  of  the  position,  I  will  quote  three  opinions. 

"Pridgen  Teale,  writing  in  the  British  Medical  Journal,  says  : 
'The  patient  breathes  the  same  air  over  and  over  again, 
*  *  *  thereby  economizing  the  heat  of  the  air  passage-^, 
economizing  ether,  and  enhancing  the  effect  of  the  ether  by 
partial  asphyxia.' 

"  Mr.  Woodhouse  Braine,  Lecturer  on  Anaesthetics  at  Charing 
Cross  Hospital,  states  that,  in  using  the  inhaler,  he  frequently 
removes  the  sponge,  and  maintains  anaesthesia  by  allowing  the 
patient  to  breathe  into  and  from  the  rubber  bag.  He  says : 
'  It  may  be  urged  against  this  method  that  the  patient  re- 
breathes  the  carbonic  acid  of  his  own  expired  air,  and  this  is 
true;  but  from  the  length  of  time  I  have  employed  this  plan, 
and  from  never  having  seen  any  deleterious  results  from  it,  I 
do  not  attach  any  importance  to  the  objection.' 

"  Mr.  Ormsby,  in  reply  to  an  inquiry,  has  kindly  written  :  '  I 
believe  that  carbonic  di-oxide  in  a  diluted  form  assists  the 
ether  as  an  anaesthetic,  while  the  rebreathing  of  the  vajjor 
warms  it,  so  that  it  is  more  readily  tolerated  by  the  patient.' 

"  In  my  own  experience,  which  has  been  extended  and  con- 
siderable, I  have  found  no  disadvantage  arising  from  the 
alleged  asphyxiation.  I  would  add  a  few  hints  as  to  the 
method  of  administration,  omitting  the  usual  preliminaries 
and  precautions,  which  should  be  observed  during  the  progress 
of  anaesthesia.  Always  measure  the  ether  used,  for  economy, 
and  in  order  to  know  how  much  is  being  consumed.  A  given 
quantity  will  yield  a  certain  result.  This  precision,  which 
obtains  in  the  majority  of  cases,  contributes  largely  to  the 
saving  in  the  drug.  Having  poured  the  ether  on  the  sponge, 
invert  the  inhaler  before  placing  it  on  the  patient's  face,  to  be 
certain  that  no  fluid  will  escape  and  startle  him. 

"As  a  preliminary  I  usually  apply  the  inhaler  with  the  air 
slot  open,  and  direct  the  patient  to  keep  the  mouth  closed  and 
breathe  slowly  and  quietly.     This  may  seem  a  triviality,  but  I 


354  ARTIFICIAL   ANAESTHESIA. 

am  satisfied  from  personal  experiment  and  frequent  experience 
that,  when  closely  followed,  it  completely  abolishes  the  trouble- 
some cough  which  usually  accompanies  the  first  inspirations. 
In  slowly  passing  through  the  nasal  cavities,  the  vapor  is 
warmed  and  fails  to  irritate  the  laryngeal  mucous  membrane. 
In  the  lungs  the  presence  of  the  reserve  air  at  first  assists  to 
dilute  the  vapor,  and  as  insensibility  sets  in,  the  respiration 
deepens.  The  inhaler  should  be  pressed  firmly  in  the  face  to 
diminish  leakage.  When  anaesthesia  is  complete,  the  instru- 
ment should  be  removed  and  re-applied,  as  occasion  demands. 

"  In  consequence  of  a  letter  which  appeared  in  the  Journalof 
the  American  Medical  Association,  for  October  16th,  1886,  I 
have  received  many  inquiries  as  to  an  inhaler  which  would 
give  the  results  there  stated.  Ormsby's  figures  for  the  old 
apparatus  were  : 

"Average  time  required  to  produce  insensibility,  2  minutes. 

"Average  quantity  of  ether  employed,  1  oz. 

"  This  is  a  fair  statement  when  calculated  from  a  large  num- 
ber of  cases,  and  the  improved  inhaler  will  give  as  good  results." 

Inhaler  of  Nitrous  Oxide  Gas  or  Ether  of  Codaiau 
&  Sluirtleflf,  of  Boston. 

The  points  for  which  they  claim  superiority,  are : — 

"1st.  Durability;  being  made  of  metal,  they  are  not  liable 
to  be  easily  broken,  as  so  frequently  happens  to  the  hard-rubber 
inhalers,  and  as  they  are  nickel-plated  they  retain  their  brilliant 
polish  without  change. 

"2d.  For  convenience  both  to  the  patient  and  operator. 
With  one  hand,  the  latter  can  apply  the  inhaler,  and  open  or 
close  the  tv/o-way  stopcock,  leaving  the  other  hand  at  liberty 
to  control  the  patient,  or  for  such  exigencies  as  may  occur.  As 
the  elastic  hood  covers  both  nose  and  mouth,  the  patient  is 
saved  the  necessity  of  having  the  nostrils  closed  either  by  clamps, 
or  the  fingers — a  part  of  the  operation  always  very  disagreeable, 
and  to  very  sensitive  patients  positively  frightful,  as  it  produces 
a  feeling  of  suffocation. 

"3d.  Cleanliness.  The  rubber  hood,  which  alone  comes  in 
contact  with  the  face,  is  easily  removed  and  replaced,  and  as  all 


CODMAN   &  SHURTLEFF'S   INHALER. 


355 


the  other  parts  are  either  metal  or  hard  rubber,  the  whole  instru- 
ment can  be  kept  perfectly  pure  by  washing,  which  is  a  point  of 
great  importance  to  the  comfort  of  the  patient. 

"4th.  Durability,  and  accurate  working  of  the  valves." 

Upon  this,  perhaps,  more  than  anything  else,  depends  the 
successful  administration  of  anaesthetics.  If  the  exhaling  valve 
does  not  quickly,  and  perfectly,  close  while  the  gas  is  being  in- 
haled, air  is  taken  with  it,  and  the  gas  is  so  much  diluted,  that 
it  very  much  delays,  or  wholly  prevents,  the  desired  eifect. 

If,  on  the  other  hand,  the  inhaling  valve  does  not  work  prop- 
erly, the  patient  breathes  back  into  the  reservoir  a  mixture  of 
nitrous  oxide  and  air. 

Plate  35  is  the  inhaler  with  a  hard  rubber  mouth-piece,  A ;  the 
metal  hood,  B,  is  used  for  nitrous  oxide  gas. 


Plate  35. 


Plate  36,  is  the  inhaler  for  nitrous  oxide  gas.      A,  metallic 
hood,  containing  B,  flexible  rubber  hood,  covering  both  nose 


Plate  36. 


and  mouth  ;  0,  exhaling  valve;  D,  two-way  stopcock;  I,  pack- 


356 


ARTIFICIAL  ANAESTHESIA. 


ing,  through  which  a  silk  cord  passes;  E,  slidiiig-joint,  where 
J,  is  detached  to  connect  the  ether  reservoir;  J,  contains  the 
inhaling  valve. 

Plate  37,  the  inhaler  arranged  for  using  ether.  This  differs 
from  Plate  36  only  in  the  addition  of  the  hollow  sphere,  F,  which 
contains  a  coarse  sponge,  on  which  the  ether  is  poured  through 
the  opening  G;  H,  cover  closing  the  reservoir  when  not  in  use. 
This  part  is  attached  at  the  sliding-joint  E,  and  will  fit  most 
inhalers  made  by  Codman  &  Sburtleff,  during  the  last  three 
years.     By  this  arrangement,  waste  of  ether  by  evaporating,  is 

riate  37. 


prevented,  and  it  is  stated  that  less  than  half  the  quantity  is  re- 
quired to  produce,  or  keep  up  ansesthesia. 

The  operator  also  escapes  breathing  so  much  of  the  ether,  as 
he  is  compelled  to  do,  when  using  it  from  a  sponge  or  napkin. 

Experiments  made  with  the  Inhaler  of  Codman  & 
Shurtleff,  Boston. — First  experiment  with  new  inhaler, 
November,  with  three  patients,  two  males,  and  one  female. 

In  each  was  tested  the  ether  attachment:  two,  were  unable  to 
make  the  valve  act  quickly ;  in  the  third,  the  operation  of  inha- 
lation was  a  success,  the  exhaling  valve  acting  with  each  respi- 
piration,  by  a  click. 

Nov.  2d.  Second  experiment,  two  females,  and  one  male. 
With  the  females  the  soft  rubber  covering  for  the  mouth,  nose 
and  face  fitted  admirably.  With  the  male,  the  rubber  cover 
could  not  be  made  to  fit  air-tight,  owing  to  his  having  a  beard. 


RAPID   ANESTHESIA    BY  ETHER.  357 

but  it  worked  more  satisfactorily.  If  the  distance  from  the 
ether  supply,  and  the  mouth-piece,  is  shortened,  the  ether  passes 
much  more  rapidly  in  the  case  of  a  patient  who  is  feeble. 

The  exhaling  valve  should  be  screwed  tightly,  else  it  is  apt 
in  handling  to  become  loose  and  will  drop  out. 

Rapid  Anaesthesia  by  Ether.* 

The  following  method  of  rapid  anaesthesia  by  ether,  was  sug- 
gested to  A.  F.  Miiller,  M.D.,  attending  physician,  Germantown 
Hospital,  seven  or  eight  years  ago,  by  a  thought  that  the 
great  length  of  time  often  consumed  in  etherizing  patients  was 
due  to  the  fact,  of  the  frequent  interruptions  necessary  to  re- 
plenish the  cone  or  towel  used  for  the  purpose,  and  the  conse- 
quent partial  recovery  of  the  patient.  To  obviate  the  difficulty 
and  obtain  a  continuous  flow  of  pure  ether  vapor,  he  had  made, 
an  apparatus,  consisting  of  the  two  halves  of  a  rubber  foot-ball, 
sewed  together  at  the  edges,  and  connected  by  a  tube  with  a 
bottle  containing  ether,  which  is  plunged  into  a  bucket  of  hot 
water.  Ether  boils  at  90°,  and  vapor  passes  over  steadily  and 
rapidly,  and  is  inhaled  by  the  patient,  whose  face  is  covered  by 
the  inhaler,  protected  by  a  clean  towel. 

The  result  has  been  surprising  to  himself,  as  will  be  seen  by 
the  following  cases,  all  etherized  by  this  method,  within 
three  months,  at  the  Germantown  Hospital.  In  none  of  the 
cases  was  there  nausea  previous  to  anaesthesia ;  one  at  least  came 
to  the  house  the  morning  of  the  operation,  having  eaten  a  hearty 
breakfast.  In  most  cases,  no  struggling,  and  if  so,  only  slight; 
no  stage  of  excitement.  In  cases  that  require  only  a  few  mo- 
ments for  operation,  the  patient  wakes  up  nearly  as  quickly  as 
after  nitrous  oxide.  After  the  patient  is  etherized,  the  amount 
passing  over  can  be  regulated  by  a  stopcock  at  the  bottle  end 
of  the  tube. 

The  apparatus  he  had  used,  was  very  crude,  made  only  for  the 
purpose  of  experiment,  and  he  is  having  an  improved  one  made, 
which  he  hopes  will  be  more  satisfactory  in  some  of  its  details. 

The  quantity  of  ether  used  to  produce  complete  insensibility 

*  Medical  Times,  April  4th,  1885. 


358  ARTIFICIAL   ANAESTHESIA. 

in  no  case  exceeded  three  ounces;  in  aome,  it  was  less  than  an 
ounce  and  a  half. 

First  Case. — D.  E.,  epithelioma  of  eyelid;  plastic  operation  ; 
unconscious  in  thirty  seconds. 

Second  Case. — K.  McF.,  periotomy;  unconscious  in  one  minute 
twenty  seconds. 

Third  Case. — K.  McF.,  periotomy;  unconscious  in  one  minute 
eleven  seconds. 

Fourth  Case. — M.  P.,  paronychia  and  palmar  abscess ;  forty- 
five  seconds. 

Fifth  Case. — Mrs.  B.,  lacerated  cervix;  one  minute  twenty 
seconds. 

Sixth  Case. — Mrs.  B.,  lacerated  cervix ;  one  minute  fifteen 
seconds. 

Seventh  Case. — Bilateral  lithotomy;  one  minute  fourteen 
seconds. 

Eighth  Case. — MissM.^dilatationof  cervix;  one  minute  forty 
seconds. 

Ninth  Case. — Mrs.  T.,  laceration  of  cervix ;  one  minute  twenty- 
four  seconds. 

Tenth  Case. — Mrs.  S.,  fracture  of  anatomical  neck  of  humerus ; 
one  minute  seventeen  seconds. 

Eleventh  Case. — Mrs.  M.,  fracture  of  tibia,  and  fibula;  forty 
seconds. 

Twelfth  Case. — Mrs.  M.,  fracture  of  tibia,  and  fibula;  one 
minute  forty-five  seconds. 

Thirteenth  Case. — Mrs.  B.,  fracture  of  tibia,  and  fibula;  two 
minutes. 

Fourteenth  Case. — Cataract;  one  minute,  fifteen  second^^. 
This  man,  when  operated  upon  in  the  Germantown  Hospital  for 
cataract  in  the  other  eye,  about  a  year  ago,  took  a  large  quantity 
of  ether,  and  required  an  hour  to  put  him  under  its  influence. 

Fifteenth  Case. — Mrs.  D.,  amputation  of  forearm ;  one  minute 
thirty  seconds. 

Sixteenth  Case. — McLane,  hypopyon ;  one  minute  twenty 
seconds. 

Seventeenth  Case. — Mrs.  S.,  lacerated  cervix  operation ;  one 
minute  thirty  seconds. 


CORNING   ON   EAPID   ANESTHESIA.  359 

Eighteenth  Case. — Cleaver,  sarcoma  of  iris;  one  minute,  twenty- 
seconds. 

Dr.  Corning,  of  New  York,  has  used  the  following  device  to 
produce  rapid  antesthesia :  "A  strong,  flat,  elastic  tourniquet 
was  secured  around  each  of  the  patient's  thighs,  so  as  to  arrest 
hoth  arterial,  and  venous  blood-flow  in  the  same.  By  this  pro- 
cedure each  limb  was  converted  into  a  species  of  receptaculum 
for  a  considerable  proportion  of  the  total  blood-mass.  The 
ligatures  being  in  place,  the  ether-cone  was  applied  over  the 
mouth,  and  face  of  the  patient,  and  in  about  three  minutes  by 
the  watch,  the  patient  was  anaesthetized.  On  the  completion 
of  the  operation,  the  ligatures  were  removed,  and  the  patient 
recovered  from  the  effects  of  the  ether  instantly.  The  rapid 
recovery,  is  somewhat  remarkable." 

Anaesthesia  was  produced  by  draining  the  blood  from  the 
head  into  other  parts  of  the  body.  In  some  of  the  hospitals  in 
Paris,  according  to  Brunton,  a  plan  was  sometimes  employed 
to  render  a  patient  insensible,  before  an  operation  by  laying  him 
flat  on  the  ground,  and  then  lifting  him  very  suddenly  to  a 
standing  posture  by  the  united  efforts  of  six  or  eight  men.  Lo- 
cal arrests  of  the  circulation  to  the  brain  have  a  similar  effect. 
"Walter"  has  recommended  diminution  of  the  cerebral  circu- 
lation, by  the  combined  effects  of  simultaneous  pressure  on  the 
carotid  arteries,  and  vagi-nerves  as  an  easy  means  of  producing 
anaesthesia  for  short  operations. 

Clover's  Inlialer  for  ]N^itrous  Oxide  and  Ether. 

This  apparatus  is  considered  by  our  English  brethren  as 
one  of  "  most  convenient  and  portable "  "  Buxton  "  for  the 
inhalation  of  ether,  and  nitrous  oxide.  This  form  of  inhaler 
was  invented  by  "  Clover ''  and  has  stood  the  test  of  a  number 
of  years'  constant  use.  It  consists  of  a  tripod  supporting  a  cast- 
iron  bottle,  containing  fifty  gallons  of  nitrous  oxide,  the  bottle 
being  gripped  firmly  by  a  screw.  The  supply  is  regulated  by 
the  administrator's  foot,  which  is  placed  upon  the  foot-piece  K. 
This  is  provided  with  teeth,  which  bite  into  the  foot  and  enable 
the  administrator,  by  turning  his  foot  to  the  left,  to  open  the 


360 


ARTIFICIAL   ANESTHESIA. 


outlet  to  the  gas.  R,  is  the  connection  between  the  bottle  and 
the  bag  G.  The  small  metallic  receiver  can  be  filled  with 
warm  water  in  cold  weather,  or  a  purifying  solution. 

The  rubber  tube  will  be  seen  to  fix  on  to  a  stop-cock  in  front 
of  the  ether  receiver,  which  latter  is  suspended  by  a  hook  from 
the  administrator's  coat.  When  only  gas  is  to  be  given,  the  stop- 


cock on  the  ether  vessel  is  put  at  right  angles  to  the  long  axis 
of  the  bag ;  when  ether  is  to  be  used,  this  stop-cock  is  turned 
into  the  long  axis  of  the  bag.  The  stop -cock  in  front  of  the 
ether  receiver  is  more  conveniently  placed,  just  above  where 
the  tube  is  seen  to  end. 

The  bag  is  so  arranged  as  to  allow  of  pure  nitrous  oxide, 
pure  ether,  or  a  mixture  of  these  two  substances  to  be  ad- 
ministered.    The  supply  is  regulated  firstly  by  the  stop-cocks 


ETHER   INHALER. 


J61 


above  mentioned,  but  more  immediately  by  an  arrangement 
represented  at  Ke.  It  consists  of  a  semicircle  of  plated 
metal,  upon  wliich  are  engraved  at  opposite  ends  the  letters 
G  and  E.  An  indicating  rod  plays  upon  this,  and  by  simply 
shifting  the  indicator  so  that  it  revolves  free  of  the  semi-disc, 
air  is  inspired.  When  the  indicator  points  to  G,  nitrous  oxide 
passes  into  the  face-piece,  and  as  the  indicator  travels  towards 
E,  ether  vapor  is  permitted  to  mix  with  the  gas,  until  arriving 
fully  at  E,  when  pure  ether  is  inhaled.  The  cushioned  foot- 
piece  is  supplied  with  a  single  expiratory  valve. 

Clovei''s  Small  Portable  Ether  Apparatus. 

Plate  39. 


Methods  of  Admiiiisteriiig'  Ether. 

The  face-piece  is  edged  with  an  air  cushion.  The  ether 
vessel  and  water  chamber  which  surrounds  it  and  maintains  it 
at  the  desired  temperature  for  evaporation,  rotate  upon  the 
mouth  of  the  face-piece.  When  the  instrument  is  first  applied, 
the  stopper  should  be  opposite  the  patient's  forehead,  and  the 
indicator  which  travels  round  the  lower  end  of  the  water 
chamber  pointing  to  the  figure  0.  The  bag  should  not  be 
placed  in  position  until  the  patient  has  taken  two  or  three  in- 
spirations ;  it  must  then  be  inflated  by  blowing  air  into  it  and 
16 


362  ARTIFICIAL  ANAESTHESIA. 

be  fitted  to  the  upper  end  of  the  water  chamber  as  shown  in 
the  figure.  As  the  ether  vessel  is  turned  round  the  indicator 
traveling  from  0  to  1,  2,  3,  and  F  successively,  the  air  has  to 
traverse  the  ether  vessel  before  reaching  the  bag,  and  so  the 
patient  gets  gradually  a  more  and  more  highly  saturated  ether 
atmosphere.  Two  ounces  of  ether  are  poured  into  the  pro- 
jecting arm  before  the  operation,  and  these  usually  suffice  for 
the  case.  The  opening  is  so  arranged  as  to  prevent  an  exces- 
sive quantity  being  used  and  to  guard  against  the  possibility 
of  a  fevi  drops  escaping  through  the  inner  openings. 

The  ether  vessel  and  surrounding  water  chamber  are  so  ar- 
ranged that,  although  the  vapor  freely  escapes,  no  fluid  over- 
flows in  whatever  position  the  inhaler  may  be  held.  The 
water  chamber  is  centred  by  a  shaft  which  communicates  with 
the  interior  of  the  ether  receptacle,  and  the  vapor  escapes  into 
this  shaft.  From  below  a  hollow  metal  cylinder  fitting  to  the 
face-piece,  and  above  shaped  like  a  clarionet  mouth-piece, 
enters  the  shaft  and  closes  it,  being  able  at  the  same  time  to 
rotate  with  the  face-piece.  To  this  is  fixed  the  long  metal 
indicator  turned  at  right  angles  at  its  extremity.  From  above 
a  similar-shaped  piece  of  metal  is  fixed,  so  that  the  two 
"clarionet"  pieces  are  adjacent,  the  lower  one  capable  of  rota- 
tion the  upper  one  fixed.  Finally  the  shaft  is  completely 
closed  above  by  the  air  bag,  which  is  attached  to  a  metal  cyl- 
inder, closing  but  freely  movable  in  the  shaft.  Ether  can 
only  reach  the  patient  when  the  two  "clarionet"  pieces 
wholly  or  partially  coincide.  When  the  lower  piece  moves, 
the  indicator  travels  with  it,  and  should  it  point  to  0,  the  ether 
way  is  blocked,  and  then  the  patient  breathes  simply  air 
through  the  shaft  in  and  out  of  the  bag.  As  soon  as  the  indi- 
cator is  moved  from  0,  the  "  clarionet "  pieces  cease  to  shut  off 
ether,  and  the  air  enters  the  chamber  and  becomes  impreg- 
nated with  its  vapor.  When  F  is  reached,  the  patient  is  in- 
haling ether  vapor  diluted  only  by  the  amount  of  air  exhaled 
from  his  lungs.  The  following  is  the  method  of  using  this 
inhaler  : — The  appropriate  sized  face-piece  being  selected  and 
two  ounces  of  ether  placed  in  the  receiver,  the  air-bag  is  re- 
moved and  the  indicator  turned  to  0.     The  patient  is  then 


ETHER   INHALER.  363 

directed  to  inspire  deeply,  and  the  face-piece  applied  firmly 
but  gently.  Uniform  pressure  is  well  borne,  while  hard  pres- 
sure, if  unequally  distributed,  will  not  be  tolerated.  When 
the  patient  has  taken  two  or  three  deep  breaths,  the  air-bag  ia 
filled  by  the  administrator  blowing  in  air,  and  is  placed  into  an 
aperture  at  the  top  of  the  dome,  so  that  the  patient  now 
breathes  in  and  out  of  this  bag.  The  indicator  is  now  moved 
to  1  so  that  the  patient  is  breathing  one-fourth  ether  and 
three-fourths  air.  A  few  breaths  of  such  a  dilution  of  ether 
will  accustom  the  larynx  to  the  irritating  vapor,  and  so  ob- 
viate coughing,  spasm,  and  the  wretched  feeling  of  suffocation 
which  ensues  upon  presenting  a  strong  ether  atmosphere  to 
the  patient  at  the  commencement  of  an  inhalation.  This  tol- 
erance achieved,  the  indicator  is  pushed  to  2,  and  the  patient 
then  inhales  half  ether  and  half  air.  If  this  strength  of  vapor 
do  not  distress  him,  the  indicator  can  be,  after  a  few  seconds, 
carried  to  3  (one-fourth  part  air,  three  parts  ether)  and  then  to 
F  (all  ether).  The  patient  will,  in  from  ninety  seconds  to  two 
minutes  and  a  half,  be  completely  unconscious  and  ready  for 
operation.  Some  persons  require  more  ether  to  put  them  off, 
and  those  who  persistently  resist  taking  the  anaesthetic  by 
holding  their  breath  or  by  taking  the  shallowest  breaths  con- 
sistent with  life,  will  delay  the  onset  of  unconsciousness  much 
longer.  These  persons  also,  since  they  voluntarily  semi-as- 
phyxiate themselves  by  repressing  respiratory  movements, 
suffer  great  additional  discomfort  from  the  feeling  of  suffoca- 
tion they  induce. 

As  soon  as  complete  anaesthesia  is  thoroughly  established, 
the  indicator  may  be  brought  back  to  2,  and  there  kept  until 
the  operation  is  over.  It  may  be  necessary  in  warm  weather, 
and  in  the  case  of  prolonged  operations,  to  renew  ether  in  the 
receiver.  This  is  easily  done  by  removing  the  inhaler  from 
the  patient's  face,  loosening  the  cork,  and  pouring  in  a  further 
supply. 

The  patient  will,  during  a  prolonged  operation,  require  the 
inhaler  taken  off  his  face  every  sixth  breath  or  so,  in  order 
that  he  may  take  a  few  inspirations  of  air.  The  necessity  for 
this  will  be  readily  recognized  by  the  degree  of  cyanosis  ap- 


364  ARTIFICIAL  ANAESTHESIA. 

parent  in  the  face,  and  by  the  character  of  the  respirations 
and  the  pulse.  It  should  be  carefully  borne  in  mind,  that  the 
amount  of  an  antesthetic  required  to  produce  narcosis  is  much 
greater  than  is  needed  to  maintain  that  condition.  Also  the 
degree  of  narcosis  must  be  varied  in  correspondence  with  the 
region  of  the  body  upon  which  operative  measures  are  being 
pursued. 

Clover's  larger  ether  inhaler  is  figured  on  p.  360.  It  is  used 
mainly,  if  not  exclusively,  for  giving  nitrous  oxide  and  ether 
in  combination.  The  method  of  using  it  without  nitrous  oxide 
is  simple.  The  air-bag  is  fully  inflated  by  the  administrator, 
who  then  moves  the  indicator  off"  the  dial  plate  and  turns  the 
ether  tap.  The  indicator  is  next  turned  to  G,  when  air  only 
will  be  taken.  As  soon  as  the  indicator  passes  towards  E, 
ether  begins  to  be  received;  the  same  principles  and  cautions 
guide  the  further  proceedings  with  this  as  were  employed  for 
the  other  inhaler. 


PAET  FOUETH. 


CHAPTER    XX. 


CHLOEOFORM. 


Chloroform — Dichlorinated    Chloride    of    Methyl — Terchloride     of 
Formyl  (CHCI3). 

/^       Chloroform  was  discovered  in  1831,  almost  simultaneously    ^\\ 
by  Soubeiran,  of  France,  Liebig,  of  Germany,  and  Guthrie,  of 
Sackett's  Harbor,  New  York, 

Its  true  constitution  was  discovered  by  Damas,  in  1834. 

The  ordinary  method  of  preparing  chloroform,  is  by  the  dis- 
tillation of  alcohol,  and  chloride  of  lime ;  but  owing  to  the 
heavy  duty  upon  alcohol,  the  following  methods  will  show 
how  it  may  be  otherwise  manufactured,  at  less  cost.  One  of 
the  new  processes  consists,  in  the  substitution  of  wood  alcohol  ^ 
s\     (being  \  less  in  price  than  grain  alcohol).  ,^-<:^^ 

\\  Wood  is  subjected  to  distillation,  and  the  result  is  pyrolig- 
neous  acid,  and  pyroxylic  spirit,  commonly  called  wood  alcohol. 
The  latter  is  separated  in  a  very  impure  state,  redistilled  with 
lime,  and  then  manufactured  into  chloroform,  in  the  ordinary 
way,  with  chloride  of  lime,  and  sulphuric  acid.  The  manufac- 
ture of  chloroform  from  pure  wood  alcohol,  is  not  entirely  new, 
but  the  value  of  the  patent,  consists  in  the  fact  of  being  able 
to  use  the  alcohol  in  a  crude  or  intermediate  state,  before  it  is 
separated  from  the  pyroligneous  acid,  and  the  other  liquid 
constituents  of  wood,  thus  reducing  the  cost  to  a  minimum. 

Chloroform  prepared  from  wood-spirit  is  specifically  lighter, 
and  has  at  times  an  empyreumatic  odor  from  acids  or  chlorin- 

365 


366  ARTIFICIAL   ANAESTHESIA. 

ated  oils,  and  gives  rise,  when  inhaled,  to  unpleasant  sensa- 
tions, with  prostration,  and  headache.  Many  chloroform  acci- 
dents are  doubtless  due  to  impurities  in  the  drug.  Sleep  is 
obtained  with  difficulty,  and  is  disturbed  in  character.  In 
some  cases,  the  attempt  had  to  be  given  up,  after  trying  suc- 
cessively, producing  disorder  of  the  stomach,  vomiting,  etc. 

Impure  and   Dang-eroiis  Chloroform. 

Some  chloroform  obtained  from  a  highly  respectable  German 
firm,  having  aroused  the  suspicions  of  operators  by  the  fre- 
quency with  which  patients  antesthetized  with  it  presented 
grave  symptoms,  Professor  Menthin,  of  Warsaw,  undertook  to 
examine  it,  with  a  number  of  chloroforms  obtained  from 
other  firms.  The  results  were,  that  not  a  single  sample  entirely 
answered  the  tests  of  the  Russian  Pharmacopeia,  which  are 
somewhat  stringent,  though  less  so,  than  those  of  the  French 
Codex.  Professor  Menthin — whose  article  is  published  in  the 
Vrach,  giving  details  and  names  of  the  firms,  from  which  the 
different  samples  were  obtained — found  that  all  the  specimens 
left  a  residue  on  evaporation,  some  of  these  residues  being  evi- 
dently of  a  very  prejudicial  character,  causing  headache,  and 
giddiness  on  prolonged  smelling.  One  of  them  smelt  at  first 
like  nitro-benzol,  with  an  admixture  of  tobacco,  the  odor  chang- 
ing in  two  days,  to  one  like  benzoic  acid.  When  heated,  this 
residue  gave  off  an  odor  resembling  burnt  india-rubber.  One 
of  these  samples  came  from  a  British  firm,  and  appears  to  have 
been  by  far  the  best  of  them  all,  thirty-nine  cubic  centimetres, 
leaving  only  a  residue  weighing  .0001  gramme,  and  having  a 
,  transitory  smell  of  malic  ether ;  whereas  forty-nine  cubic  cen-  ^ 
timetres  of  one  of  the  German  specimens,  left  a  residue  weigh- 
ing .0022  gramme,  and  of  a  peculiarly  offensive  character.  Pro- 
fessor Menthin's  investigations,  would  seem  to  offer  some  ex- 
planation of  the  extreme  care  taken  by  some  of  our  continental 
brethren,  in  regard  to  the  use  of  chloroform.  If  much  of  what 
is  used  is  as  impure  as  some  of  the  specimens  referred  to,  it  is 
scarcely  to  be  wondered  at,  that  the  results  are  sometimes  disas- 
trous. The  specimen,  which  was  the  immediate  cause  of  the 
investigation,  is  stated  to  have  produced  in  no  less  than  half  of 


PUEIFIED   CHLOROFORM.  367 

the  patients,  sucli  dangerous  symptoms,  that  its  administration 
had  to  be  discontinued.  To  all  appearances,  however,  it  was 
perfectly  good,  having  a  specific  gravity  of  1.487,  neutral  re- 
action, containing  no  free  chlorine,  and  not  undergoing  any 
change  of  color,  when  mixed  with  hot  sulphuric  acid,  and  left  to 
stand  for  twenty-four  hours.  The  sequel,  of  course,  shows  that 
these  preliminary  tests  are  very  insufficient. — Lancet,  July  6, 
1889. 

A  still  more  recent  patented  process  of  making  chloroform, 
is  termed  the  "Albany."  By  burning  acetate  of  lime,  acetone 
is  produced,  the  distillate  being  collected,  and  redistilled  with 
chloride  of  lime,  and  is  then  purified.  A  specimen  of  this 
chloroform  has  been  sent  to  us,  and  was  found  to  be  clear, 
free  from  any  empyreumatic  odor,  with  the  sweetish  burning 
taste.  It  did  not  redden  blue  litmus  paper,  but  bleached  it 
with  a  faint  reddish  tinge,  no  precipitate  with  nitrate  of  sil- 
ver, no  change  on  the  addition  of  a  solution  of  iodide,  or  per- 
manganate of  potash;  nor  was  it  blackened  by  strong  sul- 
phuric acid. 

It  acted  promptly  by  inhalation,  producing  narcosis,  but 
with  a  tendency  to  irritate  the  stomach,  causing  an  inclination 
to  vomit.     The  ansesLhetic  effect  did  not  last  long.  />,^^ 

,^y^  Commercial  chloroform,  when  obtained,  is  a  transparent,  ^^ 
heavy  liquid,  containing  98  per  cent,  of  chloroform,  fre- 
quently containing  hydrochloric  acid,  chlorine,  and  foreign 
chlorine  compounds,  with  traces  of  arsenic  as  impurities.  It  is 
therefore  unfitted  for  use  as  a  medicine,  or  as  an  anaesthetic 
agent,  until  purified.  ^/^ 

V  >^liloroforni  Purificatmn— Piii'ified  Cliloroform.     >\ 

^  (CHCI3;  119.  2— C2HCI3;  119.  2.) 

After  careful  purification,  by  means  of  distillation,  in  contact 
with  sulphuric  acid,  carbonate  of  sodium,  lime,  potash,  alcohol, 
and  water,  it  is  then  ready  for  use.  Chloroform  in  its  pure 
state  is  a  heavy,  clear  liquid,  having  a  specific  gravity  of  1.49°. 
It  has  a  characteristic,  pleasant  and  ethereal  odor,  a  burning, 
sweet  taste,  and  a  neutral  reaction.  It  dissolves  in  alcohol,  and 
ether,  in  all  proportions,  but  only  mixes  with  water  in  small    ^ 


'\ 


368  ARTIFICIAL  ANAESTHESIA. 

proportions,  and  will,  after  a  time,  sink  to  the  bottom  of  such 
mixtures  in  clear  globules,  owing  to  its  being  so  much  heavier. 
It  communicates  its  sweetish  taste  to  water.  Dose,  3  to  10  miu. 
given  in  capsules,  or  mixed  with  alcohol  as  the  spiritus  chloro- 
form, 1  volume  in  20.  Dose,  20  to  60  min.  or  in  the  mistura 
chloroformi — chloroform  8,  camphor  2,  fresh  yolk  of  egg  10, 
water  80.  Dose,  tablespoon ful.  If  a  few  drops  be  permitted 
to  evaporate  from  blotting  paper.'qo  sTnin,  or  no  forpign  nrlor 
should  be  perceptible  after  the  odor  of  chloroform  ceases  to 
be^recognized.  When  applied  to  the  skin,  chloroform  evapo- 
rates rapidly,  and    produces   a   fcpli^p;  nf  rnld.      When    the 

pvnporntinn    ja    prf^vpntprl,  it  pnrnn  (liminil]   Him  M[nilMi  iitha^  nnrl 

\      .   acts  as  an  irritant  to  the  inner  skin,  producing  rubefaction,  and 
\    \  local  anaesthesia.     (See  article  on  Local  AnaistheticiTy" 


\/\    ^o   chloroiorm  should    be    used    for  anesthetic  purposes, 
/^  which  does  not  comply  with  the  following  requirements  : 
/I         1st  test.  When  dropped  in  distilled  water,  there  should  be 
/     transparent  globules  with  no  milky  appearance. 

2d.  Chloroform  should  have  an  agreeable  odor. 

3d.  It  should  not  redden  blue  litmus  paper. 

4th.  When  added  to  a  solution  of  nitrate  of  silver,  it  should 
not  form  a  precipitate,  nor  even  cause  cloudiness. 

5th.  Test  with  a  solution  of  iodide  of  potassium  (for  free 
chlorine). 

6th.  When  brought  to  the  boiling-point  with  a  concentrated 
solution  of  caustic  potash,  it  should  not  become  colored.  (Ab- 
sence of  aldehyde  and  arsenic.) 

7tb.  Sulphuric  acid  should  not  blacken  it  when  brought  in 
contact  with  chloroform. 

8th.  Mixed  with  concentrated  sulphuric  acid  and  shaken, 
it  should  separate  in  half  an  hour,  into  two  colorless  layers. 

Chloroform,  is  liable  to  sudden  changes,  and  exposure  to 
light,  an  imperfect  stopper  or  partially  tilled  bottle,  frequently 
affect  its  purity  ;  hence  it  should  be  tested  before  using.  The 
combined  action  of  permanganate  of  potash,  and  a  caustic 
alkali,  have  been  recommended  as  exceedingly  delicate  tests, 
and,  as  such  a  re-agent,  the  following  formula  is  given  : 


w 


PURIFIED  CHLOROFORM.  369 

Permanganate  of  potash 15  grains 

Caustic  potash 2^  drachma 

Distilled  water 7^  ounces 

Purified  CMoroform— Anaesthetic  and  Physiological 
Action. 

When  one  per  cent,  of  chloroform,  is  mixed  with  three  to 
five  per  cent,  of  atmospheric  air,  it  becomes  charged  with  it, 
and  in  this  form  it  is  usually  employed  as  an  anaesthetic. 

"  The  amount  of  vapor  which  can  be  taken  up  (held  in  solu- 
tion) by  the  air  of  the  atmosphere,  varies  with  the  elastic 
tension  of  the  chloroform  vapor  at  different  temperatures. 
Thus  at  40°  F.,  a  small  quantity  of  chloroform  would  evaporate 
into  air  ;  at  130°  F.,  so  much  would  volatilize,  as  to  give  rise  to 
an  almost  pure  chloroform  vapor.  In  the  following  table, 
taken  from  Snow's  'Anaesthetics,'  the  amount  of  chloroform 
in  vapor,  is  shown  in  100  cubic  inches  of  saturated  mixture  of 
air,  and  chloroform,  at  different  temperatures  : 


Air  Vapor 

F.  per  cent.  per  oeat. 

40 94 6 

45 93 7 

50 92 8 

65 90 10 

60 88 12 

65 85 15 

70 81 19 

75 78 22 

80 74 26 

85 .  70 30 

90 65  >......  35 

"  One  grain  of  chloroform,  in  one  hundred  cubic  inches  of  air, 
produces  the  second  degree  of  narcosis,  but  never  carries  chlo- 
roformization  further.  This  corresponds  to  a  proportion  of  1 
part,  by  measure,  of  chloroform  in  16,285  parts  blood,  or 
0.0000614,  the  proportion,  by  weight.  Two  grains  in  each 
hundred  cubic  inches  of  air,  or  ^V  saturation  (unity  being  sat- 

16* 


370  ARTIFICIAL  ANESTHESIA. 

uration),  produces  the  fourth  stage  of  narcosis,  or  0.0001228 
the  proportion  by  weight. 

"Any  proportion  above  two  grains  in  the  hundred,  causes 
interference  with  respiration;  three  grains  in  the  hundred 
seems  about  the  ratio  which  renders  respiration  impossible. 
Three  grains  represent  2.3  cubic  inches  vapor,  and  as  air  at  100° 
F.  can  take  up  43.3  per  cent,  of  its  volume,  the  blood  must 
contain  from  iV  to  iV  of  the  proportion  it  is  capable  of  absorb- 
ing when  the  respiratory  centres  are  poisoned. 

"  Snow  found  further,  that  calculating  the  weight  of  the  blood 
as  thirty  pounds,  twelve  minims  of  chloroform,  in  the  circula- 
tion produce  narcosis  of  the  second  degree ;  eighteen  minims, 
the  third  degree  (surgical  ansesthesia);  twenty-four  deep  nar- 
cosis (fourth  stage),  and  thirty-six,  should  paralyze  the  medul- 
lary centres.  In  practice,  more  is  needed,  because  a  certain 
proportion  evaporates  from  the  tracheal,  and  bronchial  surfaces, 
and  is  carried  out  in  expiration.  If  twelve  minims  be  evapo- 
rated into  a  bladder,  and  inhaled  to,  and  fro,  no  more  air  being 
allowed  than  can  be  blown  from  the  lungs,  narcosis  of  the 
second  degree  actually  results.  Now,  taking  thirty- six  minims, 
as  a  lethal  dose,  the  following  considerations,  upon  which 
Snow,  strongly  insisted,  explain  how  easily  this  quantity  may 
enter  the  circulation,  if  the  administrator  be  not  perpetually 
upon  his  guard  against  over  dosage  ;  18  minims  represent  the 
amount  absorbed  to  produce  surgical  narcosis;  this  amount 
might  be  absorbed  by  the  use  of  36  minims,  the  remaining  18 
mimims  being  exhaled  as  above  mentioned.  These  36  minims 
represent  37.5  cubic  inches  of  vapor,  which,  at  60°  F.,  would 
require  257  cubic  inches  of  air.  The  300  cubic  inches  thus 
formed  would  be  inspired  in  twelve  respiratory  acts  (25  cubic 
inches  being  the  amount  of  tidal  air).  Now,  if  a  vapor  of  this 
strength  were  continuously  inhaled,  the  residual  and  coniple- 
mental  air  would  become  saturated,  and  as  about  250  cubic 
inches  represent  the  air  in  the  lungs,  this  amount  would  at 
60°  F.  contain  the  vapor  of  30  minims.  Assuming  only  half 
this  quantity  to  be  absorbed,  that  is  15  minims,  we  should  then 
have  18  +  15  or  33  minims  in  the  blood,  an  amount  almost,  if 
not  quite,  enough  to  paralyze  the  respiratory  centre.     These 


clover's  chloroform  apparatus.         371 

points  being  held  in  remembrance,  will  explain  many  cases  of 
chloroform  death,  ascribed  to  '  idiosyncrasy,'  or  the  '  fatty 
heart,'  which  stand  inexpert  chloroformists,  in  such  good 
stead.  Death  from  chloroform,  does  not,  however,  always  re- 
sult from  respiratory  paralysis. 

"  Working  in  ih.e  same  line  as  Snow,  Paul  Bert,  examined 
the  action  upon  animals,  of  small  percentages  of  chloroform 
vapor  in  air.  He  asserted  that  atmospheres  containing  chlo- 
roform below  a  certain  per  cent,  failed  to  induce  anaesthesia; 
below  a  higher  percentage,  (zone  maniable)  produced  anaesthesia, 
without  danger  to  life,  even  when  a  vapor  of  this  strength 
were  persisted  in  for  an  indefinite  period,  while  above  this 
higher  percentage  death  always  occurred.  The  lethal  per- 
centage he  found  to  be  double  the  smallest  quantity  necessary 
to  induce  anaesthesia.  Lister,  who  repeated  Bert's  experi- 
ments, found  no  true  zone  maniable  ('  workable  zone  ')  to  exist. 
Indeed,  the  French  observer  appears  to  have  overlooked  the 
important  fact,  that  chloroform  not  only  kills  by  paralysis  of 
the  heart,  but  by  failure  of  respiration.  Richardson,  whose 
views  seem  to  differ  from  those  who  adhere  to  the  percentage 
theory,  suggests  that  death  from  chloroform  is,  when  it  occurs 
in  the  latter  stage,  due  to  the  cumulative  action  of  the  drug." 
— Buxton. 

"Among  the  multitude  of  inhalers  which  have  been  devised, 
we  may  notice  Clover's  chloroform  apparatus,  which  consists 
of  a  large  bag,  capable  of  containing  a  given  volume  of  air  ; 
into  this  the  vapor  of  a  given  quantity  of  chloroform  is  allowed 
to  enter,  and  the  mixture  is  so  arranged,  that  the  tension  of 
chloroform  vapor  in  the  air  is  maintained  below  4.5  per  cent. 
The  bag  is  constructed  large  enough  to  hold  sufficient  for 
several  patients.  It  is  connected  at  one  end  by  a  flexible  tube 
with  a  face-piece,  and  at  the  other,  with  a  bellows  worked  by 
the  foot.  To  the  bellows,  is  attached  a  small  metal  receiver, 
into  which  a  known  quantity  of  chloroform  is  pumped  by  a 
graduated  syringe,  inserted  into  the  lid.  Forty  minims  of  the 
narcotic  are  supplied  with  every  thousand  cubic  inches  of  air 
pumped  in,  and  as  these  represent  forty-five  cubic  inches  of  vapor 
the  percentage  of  chloroform  never  exceeds  about  4^  per  cent." 


372  ARTIFICIAL  ANESTHESIA. 

Air  ■will  carry  more  than  double  the  amount  of  chloroform 
vapor  on  a  hot  day,  than  it  does  at  the  ordinary  temperature  of 
an  apartment,  in  winter.  The  vapor  of  all  anaesthetics  is 
considerably  heavier  than  air,  that  of  chloroform,  more  than 
four  times  heavier.  Therefore,  raising  the  apparatus,  a  few 
inches  directly  upward  from  the  patient's  mouth  and  nose, 
does  not  suspend  the  administration.  There  is  constantly  in 
the  lungs,  and  bronchial  tubes,  a  volume  of  air,  from  five  to 
seven  times  as  large  as  the  tide  of  each  respiration;  time 
should  now  and  then  be  given  for  the  vapor  of  this  resid- 
ual air  to  pass  into  the  blood.  This  is  especially  necessary 
as  complete  anaesthesia  is  approaching,  and  only  applies 
to  chloroform.  It  should  be  dropped  on  a  fine  cup-shaped 
sponge,  Esmarch's  or  Skinner's  wire  mask,  held  not  too  close 
over  the  nostrils  and  mouth,  during  inspiration,  and  in  a  reclin- 
ing position.  Both  these  inhalers  are  made  of  a  light  metal 
frame-work  or  wire,  over  which  a  thin  cloth  is  stretched,  on  the 
convex  surface  of  which  chloroform  is  added,  drop  , by  drop ; 
this  allows  a  complete  admixture  of  atmospheric  air^^ts  effects 
are  divided  into  three  stages.  The  first  effect  observed,  is  a 
peculiar  sensation  of  fulness,  similar  to  the  action  of  alcoholic 
stimulants,  with  a  feeling  of  weight  in  the  cerebrum  ;  accelera- 
tion of  the  pulse,  but  no  great  increase  in  the  heart's  action ; 
blunted  sensibility,  and  more  or  less  tinnitus  aurium.  This 
first  stage  varies  as  a  rule;  it  is  generally  short,  but  in  in- 
temperate persons  it  may  be  long,  and  violent.  In  the  second 
stage,  which  is  that  of  complete  ansesthesia,  consciousness,  and 
sensibility,  are  abolished,  pulse  slow,  and  breathing  regular ; 
the  entire  muscular  system  is  relaxed.  These  two  stages  some- 
times run  together.  The  third  stage,  is  one  usually  ushered  in 
by  stertorous,  noisy,  and  "catchy"  breathing,  with  weak,  ir- 
regular pulse,  shallow,  and  less  frequent  regpiration,  and  dilated 
pupil,  which  may  be  followed  by  paralysis  of  the  heart  and 
sudden  death. 

Death  may  also  occur  from  heart-failure,  cardiac  syncope,  or 
asphyxia,  from  too  large  a  quantity  of  chloroform  being  em- 
ployed ;  also,  owing  to  the  closure  of  the  glottis,  or  paralysis 
of  laryngeal  muscles;   also,  respiratory  failure,  or  absorption 


V 


FIRST  STAGE   OF   ANESTHESIA.  373 

.  V 

into  the  blood  and  nerve  structures,  producing  entire  alteration   / 
of  them. 

What  has  experimentation  determined  definitely  in  regard 
to  the  action  of  chloroform  ?  The  action  of  chloroform  on  the 
brain  is,  first,  congestion ;  but  when  there  is  complete  ana;s- 
thesia,  it  produces  decided  anaemia  in  man,  and  animals.  The 
muscular  excitement  of  the  second  stage  is,  according  to  ex- 
periments, purely  physical ;  and  there  is,  during  the  production 
of  anaesthesia,  a  steady  lowering  of  reflex  action. 

Chloroform  at  first  induces  contraction,  and  afterwards  much 
the  same  pupillary  phenomena  are  seen  during  the  action  of 
drugs,  which  affect  the  cerebro-spinal  system,  even  in  those, 
which,  in  the  first  instance,  produce  myosis.  In  such,  if  the 
action  of  the  drug  be  pushed,  a  stage  is  arrived  at  when  the 
function  of  the  respiratory  and  cardiac  centres  is  so  seriously 
compromised,  that  the  pupils  become  widely  dilated,  and  fixed^,^^ 


lis  may  be  illustrated,. by  the  action  ot  three  drugs — opium, 
chloroform,  and  alcohol.  In  opium  coma,  the  pupil  is  always 
firmly  contracted,  while  in  alcohol  coma,  we  can  distinguish  it 
from  opium,  if  sve  pull  the  beard,  or  hair,  as  this  act  will  cause 
temporary  dilatation. 

*In  choloroform  narcosis,  the  same  pupillary  phenomena  are 
observed  during  the  extreme  stages.  From  personal  observa- 
tions, extending  over  several  hundred  carefully  recorded  cases, 
it  is  seen  that  the  pupils  are  in  a  very  variable  state  during  the 
preliminary  periods,  much  too  variable  to  permit  any  rule 
being  formulated  regarding  them.  When,  however,  reflex 
action  is  abolished,  except  in  the  cardiac  and  respiratory 
centres,  the  pupils  become  contracted  and  fixed.  (Dr. 
MacEwen,  of  Glasgow,  stated  to  us,  that  young  operators  fre- 
quently make  the  serious  mistake  of  judging  that  the  patient 
is  ready  for  an  operation  merely  from  the  test  of  touching  the 
cornea  with  impunity,  when  an  examination  of  the  opposite  eye 
will  convince  him  that  he  has  produced  by  the  close  appli- 
cation of  the  chloroform  of  the  cloth,  nothing  more  than  a 
local  anaesthesia,  confined  to  one  eye.) 

*  "The  Pupil  in  its  Symptomological  Aspects."  Amer.  Journ.  Med.  ScL,  July,  1887. 


374  ARTIFICIAL  AN.SSTHESIA. 

Dr.  Buxton  divides  ancesthesia  from  chloroform   into  five 
/;^tages,  as  follows : 
y^^      ''III  the  first  stage — from  commencement -of  inhalation  to  im- 
'^         pairment  of  consciousness — fulness  of  the  head,  ringing,  buzz- 
ing in  the  ear,  palpitation  of  the  heart  are  sometimes  felt; 
there  is  also  some  diminution  of  common  sensation. 

"  In  the  aecond  stage,  the  mental  powers  are  impaired,  although 
not  suspended.  The  patient  remains  passive,  as  if  sleeping,  or 
occasionally  makes  a  voluntary  movement.  Sometimes  laugh- 
ing, singing,  talking  are  indulged  in,  during  this  stage.  Snow, 
believed  that  dreaming  occurs  at  this  time,  and  then  only. 
Towards  the  close,  the  patient  becomes  restive ;  he  attempts  to 
remove  the  face-piece  or  towel,  for  he  is  conscious  of  being  in- 
convenienced by  the  vapor,  but  not  of  the  necessity  for  re- 
maining passive.  Common  sensation  is  much  blunted,  so  that 
patients  submit  without  expostulation  to  painful  manipulation. 
This  degree  of  narcotism  is  sufficient  for  obstetric  practice,  and 
the  after-stage  of  prolonged  operations.  As  a  rule,  struggles 
or  expressions  of  pain  which  show  themselves  at  the  time,  are 
not  subsequently  remembered. 

"In  the  third  stage  all  voluntary  movements  are  lost.  The 
conjunctival  vessels  become  full,  the  muscles  rigid,  and  strug- 
gles, even  epileptiform  convulsions,  may  supervene.  As  the 
stage  advances,  ihe  muscles  relax.  Inarticulate  jabbering,  and 
mouthing  occur.  Although  really  insensitive  to  pain,  the 
patient  may  flinch,  or  even  cry  out.  Later  in  this  stage,  all 
reflex  acts  are  abolished,  the  conjunctival,  and  nasal  receding, 
last.     The  patella  jerk  also  persists  late,  while   under  deep  / 

anaesthesia,  the  ankle-joint  phenomenon  appears.xv-i/*-^  g^y(,jX-'C^oo  fU. 

"•In  the  fourth  stage,  breathing  is  stertorous,  the  pupils  di- 
lated, and  the  muscles  completely  relaxed  and  flaccid.  In  this 
stage,  the  patient  is  profoundly  unconscious,  and  is  drifting 
into  danger.  Such  deep  narcosis  is  seldom  needed,  save  for 
the  reduction  of  old-standing  dislocations,  etc. 

"  The  fifth  stage  is  the  interval  which,  following  the  fourth 
degree  of  narcosis,  intervenes  between  the  respiratory  em- 
barrassment, and  total  cessation  of  breathing.  Even  after 
dyspnoea  has  passed  into  apncea,  the  heart  continues  to  beat  for 


W 


w 


ACTION   OF  CHLOROFOEM.  375 

a  brief  while.  Tliis  stage  marks  the  period,  when  chloroform 
tension  in  the  blood,  is  great  enough  to  paralyze  the  respiratory 
centres  in  the  medulla  oblongata,"  ^ 

The  third  stage,  may  be  regarded  as  the  safety  zone  of  com- 
plete chloroform  narcosis.  But  if  aDa3sthesia  be  pushed  beyond 
this  stage,  wide  dilatation  of  the  pupils  ensues,  indicating  a 
suspension  of  function  in  the  cardiac  and  respiratory  centres. 
This  is  a  most  critical  condition,  though  one  by  no  means  neces- 
sarily fatal,  as  by  lowering  the  head  and  raising  the  floor  of  the 
table,  and  by  promptly  carrying  out  artificial  respiration,  even 
while  feeble  respiratory  efforts  are  being  made  by  the  patient, 
the  danger  may  be,  and  frequently  has  been,  averted.  Given  a 
person  free  from  organic  lesion  of  the  nerve  centres,  heart  or 
lungs,  in  whom,  during  chloroform  narcosis,  stable  mydriasis 
suddenly  occurs,  as  a  result  of  the  action  of  chloroform  on  the 
respiratory  centres,  the  patient  ought  to  recover,  if  artificial 
respiration,  coupled  with  the  lowering  of  the  head,  be  promptly 
resorted  to,  and  the  former  eflSciently  carried  out.  It  is  interest- 
ing to  note,  in  such  cases,  the  marked  effect  produced  by  elevat- 
ing the  foot  of  the  table,  so  as  suddenly  to  place  the  patient's 
head  and  thorax  at  a  very  low  level,  the  pupils  becoming 
quickly  contracted.  In  this  connection,  however,  it  ought  to 
be  borne  in  mind,  that  one  of  the  earliest  indications  of  a  return 
of  reflex  action,  is  vomiting,  which,  as  a  rule,  is  accompanied  by 
dilated  pupils,  the  result  of  cerebral  anaemia. 

In  cases,  where  the  functions  of  the  cerebro-spinal  system, 
especially  of  the  cardiac  and  respiratory  centres,  have  already 
been  enfeebled  (by  organic  lesion  or  otherwise),  chloroform 
acts  mbre- powerfully ;  a  few  whiffs  sufficing  to  induce  complete 
insensibility,  and  the  administration  of  an  ordinary  dose  giving 
rise  to  an  alarming  state,  which  only  prompt  measures  can 
prevent  from  becoming  fatal.  In  such  cases  the  pupils  very 
readily  pass  into  wide  dilatation,  with  a  very  small  amount  of 
chloroform. 

When  the  function  of  the  brain  is  suspended,  by  want  of 
oxygenated  blood,  the  pupils  are  widely  dilated  and  fixed. 

This  may  be  seen  in  cases  of  asphyxia,  either  by  poisonous 
gases  or  arising  from  mechanical  causes.     It  was  once  observed 


376  ARTIFICIAL  ANAESTHESIA. 

by  Dr.  MacEwen,  in  two  men,  who  had  all  but  succumbed  by 
inhaling  coal-gas,  emanating  from  a  broken  gas-pipe  in  their 
bed-room,  and  it  is  also  seen  in  cases  of  hanging. 

The  Pupil  as  a  Guide  in  Givingr  Chloroform. 

Neilson,  considers  the  condition  of  the  pupil,  a  reliable  indi- 
cation of  a  patient's  condition,  under  chloroform  anaesthesia, 
and  concludes  from  his  experiments,  as  follows:  »  , 

^^      1.  The  effect  produced  by  chloroform  on  the  pupil,  is,  at  first,       \.| 

^        dilatjitioa,  varying  in  degree  and  duration,  then  con^rg^^tinn  !ia 

the  narcosis  becomes  profound,  and  dilatation  again  when  \h9^. 
^ensibility  is  returning.  If  the  administration  be  stiil  contin- 
ued, with  the  pupil  strongly  contracted  and  motionless,  the 
pupil  will  also  dilate,  but  in  this  case  more  suddenly  and  com- 
pletely, and  will  be  coincident  with  a  state  from  which  it  will 
be  difficult  or  impossible  to  resuscitate  the  patient.  This  latter, 
is  the  dilatation  of  asphyxia. 

2.  So  long  as  the  2)upil  dilates,  in  response  to  excitation  by 
pinching,  etc.,  the  patient  is  not  sufficiently  narcotized  for  the 
operation  to  be  proceeded  with,  unless  the  latter  is  slight,  and 
does  npt  require  complete  aDa?sthesia. 

3.  When  the  pupil  becomes  strongly  contracted,  and  immo- 
bile, no  more  chloroform  should  be  given,  until  it  hpyins  to  di- 
late again^^J[f,  then,  further  anaesthesia  be  required,  a  little 
more  chloroform  should  be  given  until  the  pupil  again  contracts. 

4.  The  occurrence  of  sickness,  causes  dilatation  similar  to,  but 
more  sudden  than,  that  which  happens  when  sensibility  is  re- 
turning, and  the  efforts  of  vomiting  have  the  effect  of  arousing 
the  patient. — British  Medical  Journal,  July  30,  1887. 

During  the  first  half-minute  of  the  inhalation  of  chloro- 
form, there  is  a  progressive  lowering  of  the  arterial  pressure. 
Chloroform,  if  injected  into  the  jugular  vein,  instantly  arrests 
the  heart's  action. 

Chloroform  produces  contraction  of  the  red  blood  disks;  if, 
however,  air  be  admitted  to  blood  containing  chloroform,  the 
red  corpuscles  rapidly  disappear,  dissolving  in  the  serum, 
out  of  which,  after  a  time,  htematin  crystallizes.  One  author- 
ity  states,  that   after    anaesthesia,  bile-acids   appear    in    the 


TOXICOLOGICAL    EFFECTS.  377 

blood ;  and  it  has  been  found  that  the  oxygen  of  the  blood 
undergoes  an  increase  during  anaesthesia.  During  the  ac- 
tion of  chloroform,  the  temperature  falls,  the  circulation  is 
retarded,  and  the  skin  gives  off  less  insensible  perspiration.  " 
According  to  the  recent  experiments  of  Eanke,  which  we 
have  before  referred  to,  and  repeated,  on  several  small  ani- 
mals (and  this  is  also  the  view  of  the  -late  Claude  Bernard), 
the  nature  of  the  action  of  chloroform  upon  the  nerve  cells, 
is  slight  coagulation  ;  but  if  the  animal  was  killed,  with  the 
chloroform,  there  was  hardening  of  the  nerve  trunks  and  en. 
tire  change,  in  which  evident  coagulation  of  the  albuminoid 
tissues  took  place.  If  chloroform  was  mixed  with  blood  not 
exposed  to  the  air,  there  is  no  change  except  contraction, 
either  shown  under  the  microscope  or  by  spectrum  analysis; 
this  we  have  repeatedly  determined  in  the  frog,  rabbit, 
pigeon,  etc. 

Toxlcological  Effects. 

Chloroform  is  the  most  potent  and  agreeable  anaesthetic,  but 
the  most  dangerous,  and  is  the  one  in  which  death  may  occur 
at  any,  and  every  stage  by  inhalation.  Chloroform  kills  so  sud- 
denly, that  neither  skill  nor  care,  can  always  guard  against  afatal 
result.  Another  disadvantage  of  chloroform  is  its  high  boiling- 
point,  requiring  a  great  amount  of  heat  and  vital  force  to  exter- 
"minate  it  from  the  body^so  that  it  is  probablv  never  eliminated 
entirely  by  the  lungs,  but  only  with  the  aid  of  all  excreting  or- 
gans. Any  deficiency  or  derangement  of  the  body,  which  may 
consequently  lead  to  such  suppression  or  elimination,  causes 
the  nervous  system  to  be  overwhelmed,  with  consequent 
inactivity.  Almost  all  anaesthetics  may  kill  during  the  first 
stage  by  asphyxia;  the  air  may  be  very  highly  charged — even 
saturated — with  the  agents ;  so  much  so  that,  owing  to  its 
pungency,  it  cannot  be  breathed,  and  if  forced  upon  the 
patient,  stifles  and  suffocates  him  in  exactly  the  same  man- 
ner as  would  sulphur  burned  under  his  nostrils;  death  would 
thus  occur,  without  much  having  entered  the  body. 

Owing  to  the  danger  which  accompanies  its  use,  chloroform 
should  not  be  administered  when  other  anaesthetics  are  avail- 
able ;  or  under  the  especial  circumstance  that,  without  it,  the 


378  ARTIFICIAL  ANESTHESIA. 

shock  of  the  operation  might  kill  the  patient.  In  railroad 
accidents,  and  military  surgery,  it  becoraes  at  times  absolutely 
necessary  ;  and  in  the  holds  of  ships,  especially  those  of  iron, 
Ti'here  the  temperature  is  very  high,  it  is  resorted  to  on  ac- 
count of  its  rapidity  of  action,  smallness  of  quantity  re- 
quired, cheapness,  small  bulk  in  transportation,  and  the  less 
risk  of  explosion  and  ignition.  In  obstetrics,  chloroform  is 
used  with  comparative  safety  to  the  mother,  although  a  few 
deaths  have  been  reported ;  but  from  our  observations  taken, 
in  carefully-watched  cases,  it  is  apt  to  be  fatal  to  the  infant. 
Conclusions  have  been  drawn,  that  in  long  and  instrumental 
labors,  ether,  or  bromide  of  ethyl,  although  not  so  pleasant, 
are  much  safer  to  the  child. 
//  Thesymptomswhichusually  occur,  as  precursors  of  death  from  \\ 
' '  chloroform,  are  asudden  paleness,  or  lividity  of  the  countenance, 
shallow  breathing,  stertor,  loss  of,  or  a  quick  and  weak  pulse, 
tossing  about  of  the  patient,  delirium,  convulsions  or  coma.  __,^^--;;^ 

Schifi",  (r/«i/)ar2ia^e)  arrived  at  the  following  conclusions,  aft^r"'^ 
more  than  five  thousand  experiments,  as  to  the  difference  of 
anaesthesia,  by  ether  or  chloroform :  "Ether  paralyzes  first  the 
respiration,  and  after  that  the  blood-vessels,  and  the  heart; 
while  chloroform  cat^  paralyze  tji^  h^art^  and  l^lood-veasela  at 
once,  without  previously  paral3"zing  the  respiration.  Artificial 
respiration  with  the  latter  ag^nf,  is  fhpn  nsp.lpss  ns  OYygpnai.inn 
has  ceased  ;  compression  of  the  abdominal  vessels,  and  lowering 
of  the  head,  may  be  of  advantage.  Chloroform  can  cause  death, 
at  the  first  inspiration.     Ether  is  safer  and  less  dangerous."  * 

Chloroform  should  never  be  administered  in  a  sitting  posture, 
Dor  should  a  patient  rise  suddenly  when  under  its  influence. 

What  is  the  chief  danger  to  be  apprehended,  when  chloro-         Vv 
form  has  been  used,  and  how  do  we  prevent  fatal  symptoms,  aa 
closure  of  the  glottis,  fainting,  failure  of  the  pulse,  or  respira- 
tory syncope? 

Stop  the  administratioci  of  the  chloroform,  lower  the  head  at 

*Dr.  tawrie  and  the  Nizam  Commission  of  India,  after  numerous  experiments, 
have  decided  that  death  from  chloroform  is  not  from  paralysis  of  the  lieart,  but  kills 
by  stopping  the  respiration.  According  to  the  Loudon  Luncel,  Dr.  Lauder  Bruuton 
will  pay  a  visit  to  India  to  test  the  results  of  the  Hyderabad  Chloroform  CommissioD. 


/ 


PEEVENTION    OF   FATAL   RESULTS.  379 

y^^2:a.  angle  of  forty  degrees,  and  elevate  the  feet  above  the  level 
of  the  body,  and  remove  what  mucus  or  blood  that  may  col- 
lect in  the  mouth  during  the  operation.  Draw  out  the  tongue, 
and  retain  it  out  by  a  ligature,  Ketch  forceps,  or  dry  towel,  and 
elevate  the  jaw,  and  above  all  use  artificial  respiration.  Ad- 
minister from  ten  to  twenty  drops  of  nitrite  of  amyl,  if  the  face 
is  pale,  but  not,  if  flushed ;  drop  from  a  bottle  on  a  piece  of  cloth 
and  hold  it  to  the  nose  and  mouth.  If  the  patient  makes  no 
effort  to  breathe,  force  it  up  the  nostrils  by  means  of  a  small 
hand-spray  compressing  apparatus,  and  expand  the  chest  by 
manipulation  with  the  elbows  to  the  side,  and  compress  the 
chest.  This  should  be  continued  until  the  heart  acts.  Flagella- 
tion with  towel  wrung  out  of  ice  water  is  very  useful,  but  do 
not  chill  the  patient.  If  there  is  still  increased  narcosis,  em- 
ploy hypodermic  injections  of  water  of  ammonia  (containing 
five  per  cent,  of  ammonia  gas)  to  the  quantity  of  a  drachm,  or 
two,  or  solution  of  sulphate  of  atropia.  But  depend  chiefly  on 
lowering  the  head,  and  artificial  respiration  long  continued. 
Give  the  patient  plenty  of  fresh  air  by  opening  the  windows  ; 
if  cold  cover  with  blankets.  Apply  a  galvanic  or  Faradaic 
current  during  the  artificial  respiration,  one  electrode  to  the 
base  of  the  neck,  and  the  other  to  the  epigastric  region,  on  a 
line  with  the  diaphragm,  but  not  in  the  region  of  the  heart  or 
solar  plexus.  Let  the  assistants,  or  nurses  rub  each  extremity 
briskly,  and  use  even  slight  blows,  on  the  neck,  and  side  of  the 

X chest,  but  not  on  the  stomach. 
It  is  not  safe  to  continue  an  operation  immediately  on  a 
patient's  recovery  from  the  excessive  action  of  anaesthetics,  but 
to  wait  until  respiration  has  been  energetically  restored  ;  other- 
wise, a  new  and  generally  fatal  asphyxia  may  be  produced. 
.  It  is  well  to  remember  that  anemia  of  the  brain  is  secondary 
to  the  cessation  of  the  heart's  action,  and  that  to  restore  vitality 
to  the  brain,  requires  that  the  heart's  action  be  restored.  For 
this  purpose,  as  we  have  stated  before,  there  is  nothing  bet- 
ter than  lowering  the  head  and  artificial  respiration,  and  the 
use  of  it  is  to  be  continued,  not  only  for  a  few  moments,  but 
for  hours ;  indeed,  recoveries  have  occurred  after  the  use  of 
the  Faradaic  current  and  artificial  respiration  for  one  hour. 


380  ARTIFICIAL,   ANiESTHESIA. 

Chloroform  Accirtents. 

Apropos  of  a  recent  discussion  in  the  Paris  Academie  de 
Medecine,  Prof.  Dastre  classifies  the  causes  of  fatal  accidents 
resulting  from  the  administration  of  chloroform  as  follows: 
Primary  syncope,  respiratory  or  cardiac;  secondary  syncope; 
toxic  apnoea.  In  the  first  class  death  results  from  the  first 
inhalations  (initial  shock);  this  occurs  from  reflex  cardiac 
syncope  in  nervous,  impressionable  individuals  weakened  by 
suppuration  or  hemorrhages,  or  in  individuals  otherwise 
healthy  who  suffer  from  irregularity  of  the  heart's  action  (in 
animals  with  those  which  exhibit  habitual  cardiac  irregu- 
larity, as  the  dog),  or  they  arise  from  reflex  apnoea  under 
analagous  conditions.  In  the  second  class  (secondary  or 
bulbar  syncope)  narcotism  is  more  advanced  ;  the  heart's  ac- 
tion may  be  arrested  suddenly  or  gradually ;  the  arrest  of 
respiration  may  be  slow  and  progressive,  or  sudden  from  tetanic 
spasm  of  the  glottis.  The  third  class  of  cases  comprises  those 
of  fatal  intoxication  in  which  the  agent  has  been  administered 
too  freely  or  for  too  long  a  time,  and  the  anatomical  elements, 
particularly  the  nerve  elements,  have  lost  their  vitality.  In 
this  form  of  chloroform  poisoning  there  is  a  destruction  of 
mechanism  which  seems  to  involve  derangement  of  the  en- 
tire respiratory  apparatus. 

The  real  danger  in  the  administration  of  chloroform  is  from 
the  effects  produced  upon  the  heart  and  not  from  those  upon 
the  respiratory  organs.  In  the  case  of  heart  failure  we  are 
practically  without  resource,  while  in  the  case  of  respiratory 
insufficiency  we  have  a  remedy  in  artificial  respiration.  In 
opposition  to  the  generally  accepted  opinion,  the  arrest  of  the 
heart's  action  is  a  phenomenon  of  excitation  and  not  of  paral- 
ysis or  paresis.    This  is  true  of  at  least  four  out  of  five  cases. 

As  a  remedy  for  chloroform  intoxication  Prof.  Dastre  pro- 
poses a  mixed  form  of  chloroform  administration.  Inasmuch 
as  in  the  majority  of  cases  it  is  the  stimulation  of  the  inhibi- 
tory cardiac  apparatus  that  is  concerned,  section  of  the  two 
vagi  nerves  would  constitute  the  theoretical  remedy.  This 
being  inadmissible,  we  have  still  a  practical  and  delicate 
means  of  arriving  at  the  same  result,  ^.  e.,  the  administration 


CHLOEOrOEM    ACCIDENTS.  381 

of  atropin.  This  is  really  equivalent  to  section  of  the  vagus, 
■which  destroys  the  excitability  of  the  cardiac  filaments  as  well 
as  their  bulbar  nucleus.  Atropin,  however,  should  not  be  em- 
ployed alone  on  account  of  its  excitative  tendencies,  which 
may  be  obviated  by  the  concomitant  administration  of  ils 
antidote,  morphine.  The  action  of  the  combination  of  atro- 
pin, morphine  and  chloroform  has  been  experimentally  tested 
in  the  case  of  dogs.  The  dog  is  infinitely  more  subject  to 
chloroform  accidents  than  is  man.  In  the  laboratory  of  Sor- 
bonne  one  dog  in  three  was  lost  by  accident.  During  the  last 
ten  years  all  the  dogs  have  been  anaesthetized  by  the  mixed 
method,  and  in  hundreds  of  cases  of  narcosis  there  has  not 
been  a  single  death.  The  mode  of  procedure  is  as  follows : 
Ten  minutes  before  the  operation  a  subcutaneous  injection  is 
made  of  a  solution  containing  2  centigrams  of  muriate  of  mor- 
phia and  2  milligrams  of  sulphate  of  atropia  per  cubic  centi- 
metre. Of  this  half  a  cubic  centimetre  per  kilogram  of  the 
animal's  weight  is  used.  The  administration  of  chloroform  is 
then  begun,  2  or  3  grams  being  sufficient  to  produce  a  perfect 
anaesthesia  lasting  two  hours — a  much  less  quantity  than 
would  otherwise  be  required,  while  the  economy  in  its  use 
greatly  diminishes  the  danger  of  fatal  results.  This  mixed 
method  has  also  been  used  in  human  surgery,  particularly  by 
M.  Aubert  and  his  surgical  colleagues  of  Lyons,  who  employ 
the  following  formula:  An  injection  is  made  from  fifteen  to 
thirty  minutes  before  the  operation  of  1^  cubic  centimetres  of 
the  following  solution : 

Muriate  of  morphia 10  centigr. 

Sulphate  of  atropia 5  milligr. 

Distilled  water 10  grams. 

M.  Aubert  gave  an  account  of  his  experience  with  the 
method  (Soc.  Biol.,  April  21,  1883)  in  these  terms:  "I  know 
of  nothing  more  desirable  or  practicable.  The  advantages  are 
the  following:  1,  safety;  2,  the  great  rapidity  with  which 
sleep  is  produced ;  3,  the  absolute  repose  of  the  patient ;  4, 
the  quick  return  of  consciousness ;  5,  the  absence  of  un- 
pleasant sequelae  such  as  vomiting.    Some  of  my  colleagues 


382  ARTIFICIAL   ANESTHESIA. 

have  at  my  suggestion  employed  the  method,  and  M.  Gayet 
particularly  recommends  it  in  ophthalmological  surgery." 
The  number  of  instances  of  its  employment  now  amounts  up 
(1887)  into  the  thousands,  and  without  the  occurrence  of  a 
single  accident. — La  Semaine  Medicale,  August  28,  1889. 

Sims,  on  Resuscitation  from  Chloroform. 

It  was  noticed  by  the  late  Dr.  M.  Sims,  the  celebrated  sur- 
geon, that  when  chloroform  was  too  freely  employed,  it  pro- 
duced deadly  symptoms,  so  that  the  parts  assumed  a  peculiar 
bluish-livid  appearance,  and  the  blood  became  stagnant.  He 
also  noticed  and  always  depended  upon,  first,  failure  of  the  heart 
by  the  pulse,  then  the  breathing.  He  considered  the  first  and 
best  thing  to  be  done,  was  to  invert  the  body,  the  head  hang- 
ing down,  while  the  heels  should  be  raised  high  in  the  air. 
Then  with  the  handle  of  a  spoon,  the  jaws  are  to  be  held  open 
with  a  tenaculum  hooked  in  the  tongue,  and  given  in  charge 
of  an  assistant,  whilst  to  another  is  delegated  the  duty  of  mak- 
ing efforts  at  artificial  respiration  by  pressure,  alternating  from 
the  thorax  to  the  abdomen.  Sometimes  the  patient  has  to  be 
held  in  this  inverted  position  from  fifteen  to  twenty  minutes, 
until  respiration  is  restored.  As  well  expressed  by  Dr.  Sims, 
when  caught  with  such  a  patient,  he  confesses  that  never  be- 
fore, or  since,  has  he  felt  such  a  grave  responsibility.  Some- 
times there  is  danger  in  raising  the  patient's  head  and  begin- 
ning the  operation  too  soon,  when  a  second  time  this  whole 
process  has  to  be  repeated  with  more  or  less  success. 

While  practicing  in  the  North,  Dr.  Sims  expressed,  and  pub- 
lished, the  following  opinion  :  "  Many  years  ago,  I  imbibed  the 
convictions  of  my  countrymen  against  chloroform  in  general 
surgery,  and  have  always  used  ether  in  preference,  never  feel- 
ing the  least  danger  from  it  under  any  circumstances.  It  is 
otherwise  with  chloroform." 

One  of  the  last  means  to  be  resorted  to,  is 

Surgical  Punctuke  of  the  Heart  for  the  Belief  of 
Chloroform  Narcosis. — Attention  has  been  recently  called 
to  the  importance  of  puncturing  the  heart  in  chloroform  nar- 
cosis.    We  have,  therefore,  collected  all  the  recent  important 


DR.  watson's  experiments.  383 

information  on  the  subject.  One  of  the  articles*  to  be  discussed 
will  be  that  of  experiments  of  Dr.  Watson,  of  Brooklyn,  New 
York. 

Puncture  of  the  Heart,  akd  Vena  Cava  in  Man. — 
Puncture  of  the  vena  cava,  was  followed  by  death  in  one  case, 
and  in  our  reports  of  deaths  from  chloroform,  puncture  of  the 
heart  was  performed,  but  with  no  benefit  to  the  patient.  Dr. 
Wm.  H.  Pancoast,  tapped  the  jugular  vein  in  one  case ;  also 
used  other  means  to  resuscitate  the  patient,  but  was  unsuc- 
cessful. 

A  case  in  England,  which  has  been  reported  under  the  head 
of  deaths  from  chloroform,  where  the  heart  was  punctured, 
proved  to  be  a  failure  also. 

Dr.  Watson's  experiments  show,  that  he  had  repeatedly  ex- 
cited the  action  of  the  heart  in  dogs,  after  that  member  had 
ceased  to  beat.  In  one  instance  he  punctured  four  minutes 
after,  and  received  no  response.  He  gives  the  following  rea- 
sons for  preferring  the  ventricle.  The  propelling  power  re- 
sides in  the  strong  muscular  ventricles :  There  is  another 
reason  for  not  puccturicg  the  right  auricle :  it  is,  that  since 
the  walls  are  thin,  the  puncture  endangers  the  life  of  the  pa- 
tient, from  the  consequent  leakage.  When  left  in  the  walls  of 
the  ventricle,  the  needle  does  not  produce  laceration,  but  will, 
if  left  in  the  thin  walls  of  the  auricle.  Dr.  Watson  found  the 
same  pathological  conditions  when  chloroform  is  used  upon 
dogs,  as  when  it  is  used  upon  men.  It  was  found  that  the 
heart  was  in  diastole,  and  that  the  veins  of  the  lung  were  en- 
gorged, unless  previous  hemorrhage  had  taken  plac  e. 

In  regard  to  atropia,  greater  confidence  was  placed  in  a  nee- 
dle-thrust into  the  heart,  than  in  atropia.f 

That  a  heart  that  has  recently  ceased  to  beat  can  often  be  re- 
started by  needle  puncture,  etc.,  has  been  known  for  physiological 
ages,  and  it  needed  no  further  lengthened  series  of  experiments  to 
demonstrate  it.  In  1884,  Professor  Kronecker,  then  of  Berlin,  as- 
certained, at  first  accidentally,  that  a  needle  thrust  into  the  heart 
of  a  dog  may  arrest  the  ventricular  beat  and  substitute  for  it  a 

*3Iedical  News,  June  4, 1S87. 

■f  See  Wesley  Mills'  reply  to  Watson,  showing  danger  of  puncture. 


384  ARTIFICIAL   ANJSSTHESIA. 

fibrillar  action,  a  sort  of  incoordinated  movement  of  the  muscu- 
lar fibre,  quite  ineffective  in  expelling  any  blood  from  the 
organ.  The  auricles  continue  to  beat  as  usual,  and  while  they 
remain  amenable  to  the  action  of  the  vagus  nerve,  the  ventri- 
cles pass  wholly  beyond  its  control.* 

Watson,  it  will  be  seen,  by  our  account,  advocates  puncture 
of  the  heart  in  chloroform  narcosis,  to  stimulate  the  fibres 
mechanically,  but  in  this  procedure  there  is  not  only  the  dan- 
ger of  hemorrhage,  but  it  is  quite  possible  that  Kronecker's 
co-ordination  centre — which,  in  the  dog,  occupies  the  lower 
part  of  the  upper  third  of  the  ventricular  septum — might  be 
touched,  in  which  case  immediate  death  would  follow.  "  In 
puncturing  the  right  auricle,  it  is  well  to  bear  in  mind,  that 
this  cavity  is  also  always  reached  by  a  needle-thrust,  close  to  the 
sternal  margin  at  the  right  interspace.  In  five  bodies,  recently, 
(Amer.  Jour.  Med,  Sci.,  March,  1888,  p.  290)  a  needle  so  in- 
serted, entered  the  appendix  in  two  cases, — in  one,  close  to  the 
fringed  edge  ;  in  one  case,  the  auriculo-ventricular  groove  was 
punctured,  and  in  two,  the  needle  entered  the  base  of  the  right 
ventricle.  With  a  greatly-distended  right  auricle,  it  might 
be  safer  to  puncture  outside  the  line  of  the  internal  mammary 
artery — say  an  inch  and  a  quarter  from  the  sternal  margin — 
and  carry  the  needle  downwards  and  toward  the  left." 

Watson,  concludes,  that  it  is  better  to  give  chloroform  cau- 
tiously and  with  an  a-bundance  of  atmospheric  air. 

Dr.  R.  A.  Kinlock,  states,  before  the  American  Surgical  As- 
sociation {Medical  News,  June  4,  1888)  that  he  had  punctured 
the  heart  in  a  case  of  chloroform  narcosis.  It  was  seen  that 
the  patient  was  about  to  die.  All  the  usual  expedients  were 
resorted  to ;  but  the  patient  appeared  to  be  dead.  The  ven- 
tricle was  twice  punctured.  No  effect  was  observed.  A  long 
hypodermic  needle  was  used. 

Stab  Wound  of  the  Left  Ventricle:  Recovery — 
Kiawkoff",  in  Russkaja  Medizina,  No.  42,  reports  the  case  of  a 
Cossack,  who,  in  a  quarrel  with  a   fellow-soldier,  received  a     /f^ 
stab  wound  in  the  fourth  intercostal  space  of  the  left  side,  in 

•"Surgical  Puncture  of  the  Heart,"  by  T.  Wesley  Mills,  M.A.,  M.D.,  Montreal 
Medical  News,  Vol.  LI.,  p.  39,  Philadelphia,  July  9,  1887. 


'X 


TREATMENT  OF  FATAL  SYMPTOMS.      385 

the  mammillary  line  and  parallel  to  the  ribs,  which  bled  pro- 
fusely. The  wound  was  cleansed,  a  compress  applied,  and 
restoratives  were  given.  The  area  of  dullness  was  greatly  ex- 
tended over  the  cardie  region,  but  the  patient  gradually  recov- 
ered, and  was  discharged  from  the  hospital  in  four  weeks' 
time.  Five  days  afterward,  in  attempting  to  lift  a  heavy 
weight,  the  patient  expired,  suddenly.  Post-mortem  examina- 
tion, showed  the  integument,  wound  closed  ;  the  pericardium 
was  adherent  to  the  wound.  The  cavity  of  the  pericardium 
was  filled  with  dark  blood ;  a  small  punctured  wound  of  the 
left  ventricle  was  present,  whose  edges  showed  beginning  fatty 
degeneration  of  the  heart  muscle;  subacate  endocarditis  was 
diagnosticated.  The  wound  in  the  ventricle  had  probably 
closed,  but  the  sudden  strain  had  ruptured  the  cicatrix ;  the 
endocarditis  resulting  from  the  wound  had  not  yet  been  recov- 
ered from.  The  reporter  writes,  that  seven  per  cent,  of  heart 
wounds  are  stated  to  have  been  healed.  {Centralblatt  fiir 
Chirurgie,  March  24,  1888.)* 

In  conclusion,  the  operation  is  not  recommended  by  us,  but 
as  a  last  resource,  after  all  other  measures  have  failed.  The 
insertion  of  a  needle  into  the  heart  might  excite  the  quiescent 
organ  to  action,  while  again,  it  might  cause  a  feebly  beating 
heart,  that  would  perhaps  recover  if  given  a  chance,  to  become 
hopelessly  incoordinated. 

Abstract,  as  to  tlie  Dang-ers  and  Treatment  of  Fatal 

Symptoms,  from  the  Use  of  Chloroform  as  an 

Angesthetic. 

First.  Failure  of  the  heart,  which  may  occur  at  all  stages; 
2d.  From  reflex  inhibition  by  terror ;  3d.  By  the  irritation  of 
the  vapor ;  4th.  From  chloroform  idiosyncrasy. 

Symptoms.  —  Feeble,  fluttering  pulse,  pallor,  grayness  or 
blueness  of  the  face,  ears  and  fingers,  or  a  sudden  interruption, 
or  complete  stoppage  of  the  heart  action. 

Treatment. — Careful  examination  of  the  heart,  lungs  and 


*Seea  valuable  paper  on  "The  Fatality  of  Cardiac  Injuries,"  by  H.  A.  Hare, 
M.D.,  Demonstrator  of  Therapeutics,  etc.,  in  the  University  of  Pennsylvania.  Medi- 
cal and  Surgical  Beporler,  June  22,  and  August  10, 1881. 

17 


\' 


386  ARTIFICIAL,  ANESTHESIA. 

kidneys,  and  forbidding  chloroform  in  cases  of  atheromatous 
disease  of  the  vessels,  which  can  be  felt,  fatty  degeneration  of 
the  heart,  with  great  pallor  of  skin  and  feebleness  of  action, 
aortic  or  advanced  mitral  disease,  which  must  be  deter- 
mined by  the  history,  and  stethoscope.  If  the  symptoms 
given  in  the  first  part  are  present,  the  chloroform  must  at 
once  be  removed,  the  head  and  body  inverted,  first  removing 
all  foreign  bodies  from  the  mouth;  let  limbs  be  elevated  in 
women,  and  blankets  well  wrapped  around  them,  or  the  body 
inverted  over  the  knee  of  an  assistant.  When,  as  occasionally 
happens,  the  anje^thetizer  is  single-handed,  the  raising  of  a 
patient  by  the  feet  is  practically  out  of  the  question,  except  to 
one  of  unusual  strength.  Any  one  of  good  physique  is  able, 
however,  to  accomplish  the  same  thing,  quite  readily,  by  plac- 
ing his  hands  beneath  the  patient's  hips,  and  raising  them  until 
the  leg  can  be  slipped  beneath,  and  the  patient  then  rests  upon 
his  knee,  the  foot  being  upon  the  bed.  The  head  and  shoulders 
can  now  be  swung  off  the  bed,  and  at  need  the  patient,  from  the 
head  to  knees,  brought  into  a  vertical  position.  If  the  tongue 
has  fallen  back,  draw  it  forward,  and  keep  it  held  firmly  out  of 
the  mouth.  If  the  breathing  is  not  relieved,  an  assistant  em- 
ploys Sylvester's  method  of  artificial  respiration,*  as  follows  : 
The  operator  stands  behind  the  patient  and  grasps  the  arms 
near  the  axillae;  he  first  presses  the  arms  into  the  sides,  so  as  to 
compress  the  thorax  and  expel  air,  whilst  an  assistant  makes 
gentle  pressure  upon  the  abdomen.  Next,  he  firmly  draws  the 
arms  away  from  the  sides,  everting  them,  and  lifting  the  patient 
as  the  arms  become  about  45°  beyond  the  head.  Finally,  he 
carries  the  arms  back  to  a  line  with  the  head.  He  pauses  to 
allow  air  to  rush  freely  into  the  lungs,  and  then  brings  the 
arms  down  to  the  sides  as  before.  This  process  is  repeated, 
twelve  or  sixteen  times  in  a  minute. 


♦Forced  respiration  is  stated  to  be  an  advance  upon  artificial  respiration,  and  will 
save  human  life  where  the  latter  will  fail.  According  to  Dr.  Geo.  E.  Fell,  of  Buf- 
falo, N.  Y.  {Journal  American  Medical  Association,  October,  1889),  the  apparatus 
cousists  of  a  bellows  to  supidy  a  stead}' stream  of  air,  which  passes  through  an  nir- 
heating  apparatus  ;  an  air- valve  which  controls  the  ingress  of  air  to  the  lungs,  and 
is  connected  by  an  elastic  tube  and  tracheotomy  tube  in  the  neck  and  trachea  of  the 
patient. 


TREATMENT  OF  ARRESTED  RESPIRATION.         387 

It  has  been  clearly  proven  that  in  cardiac  and  respiratory- 
failure, the  pneumogastric  nerve  retains  its  excitability  in 
chloroform  poisoning,  and  it  is,  therefore,  extremely  danger- 
ous to  apply  electricity  to  the  neck  in  this  condition.  (See 
the  experiments  and  observations  of  Doctors  Hare  and  Martin 
on  the  phrenic  nerve.) 

A  Hew  and  Only  Way  of  Raising-  the  Epiglottis. 

Dr.  Howard,  of  London,  has  endeavored  to  prove  that  trac- 
tion of  the  tongue  cannot,  as  is  supposed,  raise  the  glottis,  but 
that  the  only  way  by  which  it  can  be  certainly  raised,  is  by 
extension  of  the  head  and  neck,  whereby  its  elevation  is 
instant  and  complete.  The  patient  is  brought  to  the  edge  of 
the  bed,  or  the  chest  is  elevated,  so  that  the  head  may  swing 
free,  and  with  one  hand  under  the  chin,  and  the  other  on  the 
vertex,  steadily,  but  firmly,  carry  the  head  backward,  and 
downward,  until  the  most  possible  extension  of  the  head  and 
neck  is  obtained. 

We  had  intended  inserting  in  our  work,  the  above  paragraph, 
but  before  doing  so,  we  addressed  a  letter  to  Dr.  H.  A.  Hare, 
knowing  that  he,  in  conjunction  with  Dr.  Martin,  had  made 
experiments  on  the  subject.  He  sent  us  the  following  article, 
which  is  of  so  much  importance,  that  we  have  published  it 
entire  for  the  benefit  of  those  who  may  have  "an  urgent  re- 
spiratory crisis  in  anaesthetization." 

Tlie  Treatment    of  Arrested  Respiration  in  Anses- 
tliesia.* 

"  In  a  paper  read  before  the  Medical  Society,  of  London,  Dr. 
Benjamin  Howard,  maintains  the  following  propositions  : 

"  1.  The  epiglottis  falls  backward  in  apnoea,  and  closes  the 
glottis ;  the  first  thing  in  order  and  importance,  is  the  elevation, 
of  the  epiglottis. 

*By  Edward  Martin,  M  D.,  Instructor  in  Surgery,  University  of  Pennsylvania; 
Surgeon  to  the  Philadelphia  Hospital  and  to  the  Howard  Hospital ;  and  H.  A.  Hare, 
M.D.,  Demonstrator  of  Therapeutics,  and  Instructor  in  Physical  Diagnosis,  in  the 
Medical  Department,  and  in  Physiology,  in  the  Biological  Department,  University  of 
Pennsylvania. 


388  ARTIFICIAL  ANAESTHESIA. 

"  2.  Traction  upon  the  tongue,  however,  and  whatever  the 
force  employed,  does  not,  and  cannot  raise  the  epiglottis,  as 
supposed. 

"  3.  The  epiglottis  can  only  be  raised  by  extension  of  the 
head,  and  neck. 

"  4.  The  full  effect  of  extension  can  only  be  secured  with 
certainty,  by  making  the  extension  complete,  as  directed. 

"  5.  The  method  of  making  extension  is  as  follows :  '  Having, 
by  bringing  the  patient  to  the  edge  of  the  table,  or  bed,  or  by 
elevation  of  the  chest,  provided  that  the  head  may  swing  quite 
free,  with  one  hand  under  the  chin,  and  the  other  on  the  ver- 
tex, steadily  but  firmly  carry  the  head  backward,  and  down- 
ward; the  neck  will  share  the  motion,  which  must  be  contin- 
ued till  the  utmost  possible  extension  of  both  head,  and  neck 
are  obtained.  Sometimes  a  slight  elevation  and  exteosion  of 
the  chin  will  at  once  check  stertor,  or  irregularity  of  bieathiug ; 
but  understand,  the  extension,  which  can  in  no  case  do  harm, 
should  always  be  rather  more  than  appears  necessary.  It 
should  never  be  forgotten,  however,  that  the  full  effects  of  ex- 
tension, as  above  described,  can  be  secured  with  certainty,  only 
by  making  the  extension  complete,  as  directed.' 

"  These  propositions  are,  in  some  respects,  so  contrary  to  the 
daily  experience  of  surgeons  and  ansesthetizers,  and,  if  well 
founded,  are  of  such  supreme  importance  in  cases  of  suspended 
animation,  that  we  have  conducted  a  series  of  experiments  de- 
signed to  test,  in  so  far  as  this  is  possible,  by  working  upon  the 
dead  body,  the  validity  of  Howard's  conclusions. 

"  Limiting  our  inquiry  to  those  cases  of  threatened  death 
which  occur  from  respiratory  obstruction,  during  the  adminis- 
tration of  an  anfesthetic,  we  must  first  endeavor  to  discover  the 
mechanical  cause,  which  is  principally  operative  in  producing 
such  obstruction.  We  presume  that  by  apncea,  Howard  means, 
not  a  condition  of  suspended  respiratory  efforts  through  hyper- 
oxidation  of  the  blood,  which  is  the  true  -significance  of  the 
term,  but  cessation  of  respiratory  movement.  We  cannot  be- 
lieve the  epiglottis  is  chiefly  at  fault  as  an  obstructive  agent, 
because,  in  the  vast  majority  of  cases,  the  air-passage  is  at  once 
made  free  by  drawing  the  tongue  forward ;  since  tip-traction 


TONGUE  TEACTION   ON   THE   EPIGLOTTIS.         389 

has  no  effect  upon  the  epiglottis,  as  stated  by  Howard,  and  con- 
firmed by  our  own  observations,  this  manipulation  could  not 
relieve  the  breathing,  were  the  epiglottis  the  cause  of  the  diffi- 
culty. The  effect  of  traction  upon  the  tip  of  the  tongue,  is  to 
draw  this  organ  free  from  the  soft  palate  and  the  post-pharyn- 
geal  wall ;  it  is  the  tongue,  then,  fallen  back  upon  the  posterior 
wall  of  the  pharynx,  which  is  the  most  common  obstructing 
cause;  consequently,  the  tongue  should  receive  the  most  im- 
mediate consideration.  We  do  not  for  a  moment  deny  the 
possibility  of  respiratory  difficulty  being  caused  by  the  epiglot- 
tis alone,  though  experimentally,  the  inward  passage  of  air  was 
very  little  influenced  by  any  position  of  the  epiglottis,  provided 
the  tongue  was  carried  well  forward ;  we  would  insist,  how- 
ever, upon  the  position  of  the  tongue  as  a  matter  of  prime  im- 
portance. Considering  next  the  effect  of  tongue-traction  upon 
the  epiglottis,  we  are  not  prepared  fully,  to  endorse  Howard's 
statement.  Tip-traction,  moves  the  epiglottis,  not  at  all ;  this 
we  have  confirmed  by  many  trials,  both  in  the  living,  and  in 
the  dead  subject  ;  but  if  a  tenaculum  is  fixed  in  the  dorsum  of 
the  tongue,  two  and  a  half  inches  back  from  the  tip,  traction 
at  once  draws  the  base  of  the  tongue,  and  the  epiglottis  with  it, 
far  forward,  so  that  the  air-passage  is  absolutely  free  from  the 
larynx  to  the  mouth.  Traction  can  then,  be  so  applied  to  the 
tongue  that  the  epiglottis  is  raised,  and  the  air-way  made  ab- 
solutely free,  and  we  have  devised  an  instrument  by  which  this 
may  be  accomplished,  without  the  laceration  attendant  on  the 
use  of  hooks  or  forceps. 

"  Is  extension  of  the  head  and  neck,  the  only  method  of  raising 
the  epiglottis  ?  Again  we  are  compelled  to  take  exception  to 
Howard's  statement.  As  detailed  in  our  experiments,  the  epi- 
glottis can  be  raised  by  traction  upon  the  dorsum  of  the  tongue, 
by  pressing  the  greater  cornua  of  the  hyoid  bone  forward,  by 
the  action  of  gravity  in  the  abdominal  decubitus,  and  most 
thoroughly,  by  flexing  the  neck,  and  extending  the  head  upon 
the  neck.  That  Howard's  position  accomplishes  mechanically 
all  that  he  claims  for  it,  we  freely  grant.  The  way  in  which 
the  soft,  collapsed  structures  straighten  under  his  manipulation, 
the  tongue  riding  forward,  and  the  epiglottis  springing  erect, 


390  ARTIFICIAL  AN^STHFSIA. 

is  most  striking;  and  we  are  convinced  that  the  admirable  me- 
chanical explanation  he  gives  for  this  effect,  is  correct.  Howard 
states  : 

"'  .  .  .  by  extension  of  the  head  and  neck,  carried  to 
the  utmost  completeness,  the  backward-fallen  tongue,  the 
velum  palati,  and  uvula,  are  all  simultaneously  shifted  from  the 
air-way,  and  the  entire  pharynx  is  enlarged  throughout,  as  fol- 
lows :  a.  The  tongue,  the  dorsum  of  which  before  fell  by  grav- 
itation upon  the  then  horizontal  posterior  wall  of  the  pharynx, 
falls  upon  the  now  horizontal  arch  of  the  palate,  b.  The  velum 
palati,  by  means  of  the  great  tension  of  the  palato-pharyngei 
muscles,  is  pulled  away  from  the  posterior  wall  of  the  pharynx, 
the  entire  membrane  being  stretched  tightly  forward,  and 
downward,  behind  part  of  the  dorsum  of  the  tongue,  forming  a 
partition  which  helps  to  shut  the  tongue  out  of  the  pharynx 
and  into  the  mouth,  where  it  belongs,  and  with  part  of  the 
dorsum,  forms  the  anterior  wall  of  a  new  post-oral  air-way, 
thus  created  and  maintained,  c.  The  pharynx,  anteriorly,  is 
stretched  far  forward,  by  the  extrem  ely  tense  sterno-thyroidei 
muscles  acting  through  the  thyroid  cartilage,  by  the  genio-hy- 
oidei  and  mylo-hyoidei  muscles,  acting  through  the  os  hyoidei. 
The  base  of  the  tongue,  and  the  velum  palati,  are  shifted  forward 
in  the  manner  already  described,  the  posterior  nares  being  shifted, 
by  the  extension  of  the  head,  by  its  occipito-vertebral  articula- 
tion, about  sixty  degrees.  Posteriorly,  the  wall  of  the  pharynx 
is  shifted  back  its  whole  length  by  the  extension  of  the  cervi- 
cal vertebrae,  upon  each  other,  in  all  about  thirty  degrees,  ex- 
tension being  particularly  great,  just  opposite  the  glottis.  Thus 
the  upper  air-way,  which  before  was  a  tortuous,  angular, 
flaccid  canal, — barely,  and,  if  at  all  uncertainly  permeable, — is 
made  an  enlarged,  firm,  but  slightly  curved  tube,  free  through- 
out, from  the  glottis  to  the  nares.' 

"With  all  this,  except  the  backward  shifting  of  the  posterior 
wall  of  the  pharynx  by  extension,  we  are  fully  in  accord.  We 
cannot, however,  concede  thathis  practical  deduction  from  these 
facts,  is  a  step  in  the  right  direction.  With  the  head  and  neck 
in  extreme  extension,  the  soft  palate  is  strapped  over  the  dor- 
sum of  the  tongue,  the  mouth  is  closed  from  the  pharynx,  and 


KEEPING   THE   NOSTRILS   FREE.  391 

the  entrance  of  air  to  the  lungs  depends  absolutely  upon  the 
condition  of  the  nostrils.  Can  it  be  considered  an  additional 
safeguard — an  improved  method — to  substitute  for  the  roomy- 
mouth  an  air- way,  but  just  sufficient  at  the  best,  subject  to  an 
infinite  variety  of  obstructions,  varying  in  size  from  hour  to 
hour,  in  many  persons  absolutely,  and  permanently  occluded  ? 
Certainly  no  American  rhinologist  would  answer  in  the  affirm- 
ative. Hypertrophies,  polypoid  growths  and  vegetations  are 
not  the  rare  exception.  The  slightest  congestion,  is  frequently 
sufficient  to  block  patulous  nares.  A  nostril  which  will  admit 
the  little  finger  of  the  surgeon  when  the  patient  is  standing, 
may  become  completely  closed,  when  the  head  is  placed  on  a 
level  with  the  body.  The  recumbent  or  dependent  position, 
the  irritating  effect  of  ether  upon  the  mucous  membranes,  ceph- 
alic congestion  due  to  insufficient  oxidation,  all  combine  to 
render  the  nostrils  unsafe — in  fact,  absolutely  impracticable — 
as  the  sole  passage  of  communication  betsveen  the  lungs,  and 
the  external  air.  We  cannot  believe,  that  recourse  to  this 
method,  in  cases  of  suspended  animation  under  ansBsthetics, 
could  be  followed  by  favorable  results;  if  the  tongue  were 
drawn  forward,  it  would  certainly  provide  ample  air-way,  the 
passage  from  the  pharynx  to  the  mouth  being  opened  by  this 
manipulation.  One  of  the  great  advantages  of  this  method, 
however,  as  claimed  by  Howard,  is  that  the  necessity  for  trac- 
tion upon  the  tongue,  is  entirely  done  away  with.  If  the  ne- 
cessity for  drawing  forward  the  tongue  is  not  done  away  with, 
we  cannot  see  that  Howard's  method  offers  any  material  ad- 
vantage, over  that  ordinarily  practiced  in  this  city. 

"  Our  experiments  show  that  extension  of  the  head  carried  so 
far,  that  the  base-line,  (Reid's)  makes  an  angle  of  somewhat 
more  than  fifty  degrees,  to  the  plane  of  the  bed,  or  taale,  raises 
the  tongue  and  epiglottis  so  entirely  clear  of  the  posterior 
pharynx,  that  there  is  ample  air-way  ;  the  soft  palate,  too,  lies 
free  of  the  post-pharyngeal  wall,  but  is  not  drawn  closely 
across  the  dorsum  of  the  tongue,  thus  allowing  respiration  to 
take  place  through  the  mouth.  If,  in  the  course  of  an  anses- 
thetization,  there  is  respiratory  difficulty,  the  method  which  ob- 
tains here  is  as  follows :  The  chin  is  immediately  pressed  for- 


392  ARTIFICIAL  ANAESTHESIA. 

ward  by  the  fingers  placed  behind  the  rami  of  the  lower  jaw  ; 
at  the  same  time,  and  by  the  same  manipulation,  the  head  ia 
extended,  the  pillow,  if  any  has  been  used,  being  removed  ;  if 
there  is  still  apparent  obstruction,  the  tongue  is  now  drawn 
forward.  With  this  manipulation,  except  in  case  of  foreign 
body,  or  abnormality  of  structure,  the  air-passage  from  the 
mouth  to  the  larynx,  is  abso'iutely  free.  Hereafter,  we  may 
modify  this  method,  so  placing  the  pillow,  that  the  neck  ia 
flexed  as  far  forward  as  possible,  then  extending  the  head 
upon  the  neck,  as  we  find  that  this  gives  us  wide  dilatation, 
the  posterior  pharyngeal  wall,  representing  the  arc  of  a  circle, 
from  the  concavity  of  which  extension  of  the  head  draws  for- 
ward the  tongue,  epiglottis  and  larynx.  In  the  method  as  de- 
tailed above,  it  rarely  occurs  that  the  tongue  has  to  be  drawn 
forward. 

"  Finally,  we  cannot  grant  that  Howard  is  justified  in  believ- 
ing, of  the  hundred  cases  of  death,  due  to  the  administration 
of  an  an£Bsthetic,  that  in  each  case,  the  epiglottis  was  in  all 
probability  unraised,  and  continued  unraised  until  death  was 
complete.  The  appearance  of  the  parts  after  death,  cannot  be 
taken  as  indicative  of  their  relative  position  during  life — 
■when  inspiratory  efforts  are  still  taking  place,  when  the  rigor 
mortis  has  not  made  the  surrounding  muscles  more  rigid,  than 
the  epiglottis.  Again,  the  very  traction  upon  the  tongue,  as 
usually  exerted,  extends  the  head,  sufficiently,  to  carry  the  epi- 
glottis free  of  the  post-pharyngeal  wall.  Finally,  where  in- 
spiratory efforls  are  being  made,  there  is  no  difficulty  in  de- 
termining, whether,  or  not,  air  is  entering  the  chest;  the  noise 
of  its  passage  through  the  mouth,  and  throat,  the  respiratory 
sounds,  are  sufficiently  characteristic  of  its  free  entrance ;  while 
sinking  in  of  the  intercostal  spaces,  epigastrium,  and  supra- 
sternal region,  during  an  inspiratory  eflbrt,  are  absolutely  diag- 
nostic of  obstruction.  These  signs,  though  not  so  patent,  are 
still  sufficiently  clear  in  artificial  respiration,  and  if  the  cause 
of  death  were  even  in  the  majority  of  ca?es  simply  obstruc- 
tive, this  condition  of  obstruction,  would  unquestionably  have 
been  recognized,  and  remedied,  if  not  by  position,  certainly  by 
tracheotomy,  or  intubation. 


HARE   AND    MAETIN's   EXPERIMENTS.  393 

"  The  results  of  our  examinations,  made  upon  several  ca- 
davers, are  as  follows : 

"  By  chipping  away  the  basilar  process  of  the  occipital  bone, 
the  naso-pharynx  is  exposed. 

"  Subject  in  the  dorsal  decubitus,  head  midway  between  flex- 
ion and  extension,  eyes  looking  directly  upward,  Reid's  base- 
line (from  the  lower  border  of  the  orbit  through  the  bony 
meatus)  at  right  angles  to  the  plane  of  the  table. 

"  The  tongue  lies  in  close  contact  with  the  posterior  wall  of 
the  pharyijx,  only  the  tip  of  the  epiglottis  being  visible.  The 
soft  palate,  and  the  dorsum  of  the  tongue,  shut  the  mouth  from 
the  pharynx.  The  air-passage  is  completely  obstructed,  by  the 
tongue,  and  epiglottis. 

"  By  means  of  a  tenaculum,  passed  through  its  tip,  the  tongue 
is  seized,  and  drawn  forward,  as  far  as  possible.  The  body  of 
the  tongue,  is  drawn  clear  of  the  post-pharyngeal  wall,  and 
the  soft  palate ;  the  hyoid  bone,  the  base  of  the  tongue  and 
the  epiglottis,  are  not  at  all  influenced. 

"The  tenaculum  is  now  fixed  two  and  a  half  inches  from  the 
tip  ;  traction,  draws  both  the  base  of  the  tongue,  and  the  epi- 
glottis, well  forward. 

"  The  fingers  are  passed  behind  the  angles  of  the  lower  jaw, 
and  the  latter  is  pressed  forward  ;  this  elevates  the  epiglottis, 
and  the  base  of  the  tongue,  about  a  quarter  of  an  inch  from  the 
post-pharyngeal  wall.  Extending  the  head,  so  that  the  base- 
line makes  an  angle  of  forty-five  degrees  with  the  plane  of  the 
table,  draws  the  base  of  the  tongue,  and  the  hyoid  bone  far 
forward,  this  motion  being  at  the  same  time  imparted  to  the 
epiglottis,  so  that  the  latter  stands  upright,  and  is  separated 
from  the  posterior  wall  of  the  pharynx  by  an  interval  of  about 
an  inch.  By  tightly  closing  the  jaw,  the  autero-posterior  space, 
is  still  further  increased. 

"  The  body  is  drawn  to  the  end  of  the  table,  so  that  the  head 
hangs  free ;  the  latter  is  now  extended  until  the  base-line  is  par- 
allel to  the  plane  of  the  table  ;  the  antero-posterior  space  be- 
tween epiglottis  and  pharynx  is  slightly  greater  than  that  which 
obtains  from  moderate  extension.  At  the  same  time,  the  tongue 
drops  toward  the  roof  of  the  mouth,  the  soft  palate  is  put  upon 

17* 


394  ARTIFICIAL  ANiESTHESIA. 

the  stretch,  and  the  mouth  cavity  is  shut  out  from  that  of  the 
pharynx. 

"  Placing  the  head,  so  that  the  base-line  is  perpendicular  to  the 
plane  of  the  table,  again  produces  complete  closure  of  the 
pharynx,  owing  to  the  tongue  and  epiglottis  falling  directly 
backward. 

"Placing  the  fingers  upon  the  posterior  cornua  of  the  hyoid 
bone,  and  pressing  the  latter  directly  forward,  carries  the  epi- 
glottis, and  tongue,  about  one-half  inch  forward,  and  entirely 
free  of  the  post-pharyngeal  wall. 

"With  the  head  moderately  extended,  and  the  jaw  pushed  for- 
ward, an  effort  is  made  to  crowd  the  tongue,  and  epiglottis 
against  the  post-pharyngeal  wall ;  this  is  found  to  be  impossi- 
ble. 

"  Flexing  the  neck  by  lifting  the  head  forward,  (keeping  the 
base-line  perpendicular  to  the  plane  of  the  table)  separates  the 
post-pharynx,  from  the  epiglottis  and  the  base  of  the  tongue,  by 
about  one-half  an  inch.  Extending  the  head  upon  the  neck, 
the  neck  being  still  flexed,  produces  a  yet  wider  separation,  the 
antero- posterior  diameter  of  the  breathing  space,  being  some- 
what more  than  one  inch. 

"  Placing  the  body  in  the  position  of  abdominal  decubitus,  the 
base-line  being  perpendicular  to  the  plane  of  the  table,  the 
hyoid  bone,  base  of  the  tongue,  and  epiglottis  all  fall  forward, 
leaving  an  interval  of  about  a  half-inch  between  the  epiglottis, 
and  post-pharyngeal  wall. 

"  On  elevating  the  shoulders,  by  seizing  them,  and  lifting 
them  directly  upward,  this  space  is  increased  to  fully  an  inch  ; 
at  the  same  time  the  arytenoid  cartilages  are  drawn  backward, 
exposing  the  glottis  throughout  its  whole  extent. 

"Bringing  the  body  to  the  end  of  the  table  and  letting  the 
head  droop  forward  (still  in  abdominal  decubitus),  thus  flexing 
the  neck  to  its  full  capacity,  then  extending  the  head  at  the 
occipito-atloid  articulation,  exposes  the  larynx  more  com- 
pletely, than  any  of  the  previous  postures  or  manipulations. 

"  CojfCLUSioxs. — The  epiglottis  may  prevent  free  entrance  of 
air  to  the  lungs,  even  though  the  tongue  is  pulled  forward. 
Any  means  which  accomplishes  the  anterior  projection  of  the 


CONCLUSIONS   OF   HARE   AND   MARTIN.  395 

hyoidbone,  immediately,  and  infallibly  raises  the  epiglottis,  and 
the  base  of  the  tongue. 

"  The  hyoid  bone  may  be  made  to  project  anteriorly,  by  direct 
pressure  upon  its  cornua,  by  direct  pressure  or  traction  applied 
to  the  dorsum  of  the  tongue,  behind  the  anterior  half-arches  of 
the  palate,  by  the  action  of  gravity  in  the  abdominal  decubi- 
tus, or  by  extension  of  the  head  upon  the  neck. 

"  Extension  of  the  head  upon  the  neck,  carried  as  far  as  forty- 
five  degrees,  produces  practically  as  patulous  a  condition  of  the 
air-way  as  forced  and  extreme  extension.  At  the  same  time 
this  moderate  extension  usually  leaves  sufficient  room  between 
the  palate  and  the  dorsum  of  the  tongue,  for  breathing  to  con- 
tinue through  the  mouth. 

"  In  forced  extension  of  the  head  and  neck,  the  entrance  of  air 
into  the  lungs,  depends  upon  the  sufficiency  of  the  nasal  pas- 


"  Flexion  of  the  neck,  with  extension  of  the  head  upon  the 
neck,  does  away  with  the  epiglottis  as  an  obstructing  factor  as 
completely,  as  any  other  posture.  This  is  best  accomplished  by 
supporting  the  head  upon  a  high  pillow,  then  pulling  it  di- 
rectly backward  by  the  hand  placed  under  the  chin,  so  that  the 
weight  of  the  head  falls  upon  the  occiput,  rather  than  upon  the 
back  of  the  neck. 

"  Therefore,  in  case  of  an  urgent  respiratory  crisis  in  anaesthet- 
ization,  we  would  direct  that,  the  index  -fingers  placed  behind 
the  greater  cornua  of  the  hyoid  bone,  and  the  middle  fingers 
resting  upon  the  angles  of  the  lower  jaw,  both  these  structures 
be  pressed  directly  forward,  the  same  force  also  serving  to 
extend  the  head  upon  the  neck.  If  obstruction  to  breathing 
still  persists,  the  tongue  should  be  at  once  drawn  or  pushed  for- 
ward by  force,  exerted  upon  its  dorsum  posterior,  to  the  anterior 
half-arches. 

"  No  force,  unless  directly  applied  to  the  tongue  itself,  is  suffi- 
cient to  infallibly  prevent  this  organ  from  acting  as  an  ob- 
structing factor.  No  manipulation  yet  devised,  can,  in  every 
case,  take  the  place  of  direct  action. 

"  The  tongue  may  act  either  in  conjunction  with  the  pharyn- 
geal walls,  or  with  the  palate  in  preventing  free  entrance  of  air. 


396  ARTIFICIAL  ANiESTUESIA. 

If  the  position  of  moderate  extension,  and  direct  traction  or 
pressure  upon  the  tongue,  fail  to  remove  the  obstruction  to 
breathing,  intubation,  or  bronchotomy,  remains  as  the  last  re- 
sort." 

Ai>i>aratiis  of  Martin  and  Hare  for  the  Treatment 

of  Cases  of  Arrested  Respiration  and  tlieix 

Conclusions  in  Injury  or  Destruction 

of  the  Phx'enic  Nerve. 

"  The  apparatus  which  we  devised  for  use,  in  a  case  where  the 
body  is  too  large  to  permit  of  the  operator  swinging  it,  as  in 
the  man  and  dog,  under  similar  circumstances  to  those  named, 
was  constructed,  as  follows,  and  consisted  of  a  board  supported 
on  an  upright  of  equal  width  and  rounded  edge,  the  horizontal 
plank,  resting  by  means  of  a  groove,  on  its  under  surface,  upon 
the  convexity  of  the  vertical  support.  To  this  horizontal 
board,  is  then  bound  the  subject,  and  by  a  see-sawing  move- 
ment, the  body  is  rapidly  changed,  so  that  at  one  moment  the 
head  is  down  at  an  angle  of  forty-five  degrees  and  at  the  next 
moment  is  correspondingly  raised,  while  the  feet  fall.  In  this 
way,  the  weight  of  the  abdominal  contents  is  thrown  against 
the  diaphragm,  as  the  head  is  lowered,  and  the  air  in  the  thorax 
is  thereby  driven  out.  On  the  other  hand,  if  the  head  is 
rapidly  raised  and  the  feet  fall,  the  abdominal  contents  drop 
into  the  pelvic  space,  dragging  the  diaphragm  after  them  and 
thereby  producing  inspiration. 

"  In  order  at  the  same  time  to  extend  the  chest,  as  the  ab- 
dominal contents  sagged  downwards,  we  were  forced  to  invent  a 
simple  apparatus  which,  by  means  of  cords,  raised  the  arms 
above  the  head,  at  the  moment  that  the  feet  approached  the 
floor." 

Conchisions. 

"  1st.  Injury,  or  destruction  of  the  phrenic  nerves,  is  not  fol- 
lowed by  death,  as  has  heretofore  been  taught. 

"  2d.  That  in  injuries  involving  the  diaphragmatic  movements 
it  is  important  that  the  patient  shall  not  be  ana3sthetized,  as 
under  those  circumstances  the  absence  of  voluntary  aid  in  re- 
spiration may  be  attended  by  fatal  results. 


INJURY   OF   niRENIC   NERVE.  397 

"3d.  The  seriousness  of  phrenic  injury,  is  in  direct  ratio  to 
the  dependence  of  the  respirations  of  the  normal  animal  on  the 
diaphragm,  and  to  the  ability  of  the  chest  walls  to  make  com- 
pensatory movement. 

"4th.  The  symptoms  resulting  from  interference  with  the 
functions  of  the  phrenic  nerves  are  as  definite  and  character- 
istic, as  those  following  interference  with  any  other  motor 
nerve.  There  will  always  be  well-marked  increase  in  the 
scope  of  the  thoracic  excursions,  and  distinct  reversal  of  the 
movements  of  the  belly,  i.e.,  the  belly  will  retract  on  inspira- 
tion, 

"  5th.  Fear  of  injury,  to  one,  or  both  phrenic  nerves,  need  not 
prevent  operations  about  the  neck  and  upper  portion  of  the 
chest,  provided,  that  due  caution  be  exercised,  that  the  patient 
is  but  slightly  under  the  influence  of  the  ansesthetic  at  the 
time,  that  danger  of  injury  to  Dhese  nerves  is  most  imminent. 
Infancy,  however,  constitutes  an  exception  to  this  rule  ;  only 
absolute,  and  pressing  necessity,  for  operation  would  aiFord 
justification  for  such  a  procedure,  in  early  life. 

"6th.  The  real  effects  of  section  of  the  phrenic  nerves  being 
known,  it  follows  that  the  nerve  is  subject  to  the  same  opera- 
tion in  case  of  injury,  as  are  other  nerves  of  the  body,  such  as 
suture. 

"  7th.  The  presence  of  the  abdominal  viscera,  are  necessary 
for  the  normal  movements  of  the  diaphragm. 

"8th.  The  abdominal  contents  may  alone  be  used  for  the  pro- 
duction of  artificial  respiration,  but  while  they  are  always  to 
be  employed  to  this  end,  their  use  should  never  be  allowed  to 
displace  those  movements,  which  are  directed  to  the  chest. 
Both  should  be  used  together  if  possible. 

"  9th.  In  cases  of  injury  to  the  phrenic  nerves,  support  should 
be  given  to  the  belly  walls,  to  prevent  movement  of  the  same, 
and  to  brace  and  steady  the  paralyzed  diaphragm,  care  being 
taken  that  the  floating  ribs  are  free. 

"  10th.  The  method  of  Sylvester  drives  more  air  through  the 
lungs,  than  any  other  single  method,  but  its  best  results  are  not 
gained,  unless  the  feet  be  drawn  down  as  the  arms  are  ex- 
tended. 


398  AKTIFICIAL   ANAESTHESIA. 

"  lltli.  The  volume  of  respired  air  after  section  of  the  phrenic 
nerves  is  temporarily  decreased,  until  the  thorax  compensates 
for  the  loss  of  the  diaphragm. 

"  12th.  Oxygen  gas,  is  a  valuable  agent  in  the  treatment  of 
persons  suffering  from  coal-gas  poisoning. 

"13th.  Oxygen  gas  aids  very  materially  in  bridging  over 
the  respiratory  crisis  occurring  after  injury  to  the  phrenic 
nerves. 

"  14th.  In  life-saving  stations,  mines,  police  stations,  or  other 
points  to  which  asphyxiated  persons  may  be  brought  for  re- 
suscitation ;  in  hospital  clinics,  or  in  private  houses  where 
ether  or  chloroform  is  given,  oxygen  in  appropriate  form  for 
immediate  administration  should  be  provided.  The  accou- 
cheur also,  will  find  in  this  gas  a  valuable  adjunct  in  the  treat- 
ment of  cases  of  suspended  animation  in  the  newly  born. 
Very  small  cylinders,  containing  40  gallons  of  the  compressed 
gas,  are  easily  carried  and  require  a  small  amount  of  space. 

"15th.  The  electrical  methods  now  employed  for  the  resusci- 
tation of  persons  who  have  ceased  breathing,  are  dangerous,  and 
unjustifiable." 

On  the  Influence  of  Climate  and  Heat  on  the  Use 
OF  Chloroform. — The  following  extracts  from  letters  of  dis- 
tinguished surgeons  in   the  South,  will  show  the  influence  of- 
climate,  on  the  use  of  chloroform  : 

Dr.  Langdon  B.  Edwards,  editor  of  the  Virginia  Medical 
Monthly,  October  21,  1878,  states,  that  it  is  one  of  the  most 
peculiar  facts  he  has  ever  known  in  medical  practice — the 
difference  of  experience  in  Europe,  and  the  North,  with 
chloroform  and  ether  as  compared  with  that  of  the  South — the 
high  rate  of  mortality  in  the  North,  and  the  low  rate  in  the 
South.  Anaesthetics  are  used  for  more  trivial  affections  and 
surgical  operations  in  the  South,  than  in  the  North,  and  of 
course,  for  obstetrical  cases,  etc.  Even  during  the  war,  when 
Southerners  were  not  using  Squibb's  ether,  or  a  chloroform 
having  the  reputation  of  such  purity,  their  preference  was  for 
chloroform,  although  of  home  manufacture.  Had  a  case  that 
was  fatal  occurred  from  its  use,  in  any  of  the  small  cities  or 
towns,  it  would  have  become  wide-spread  news. 


IS   CHLOEOFOEM  SAFE   FOR  CPIILDREN?  399 

The  Use  of  Chlorofoem  in  Eegabd  to  Nationality 
AND  Race. — Dr.  M.  T.  Coomes,  of  Louisville,  Kentucky,  saya 
that  the  Irish,  as  a  class,  will  take  more  chloroform,  and  be 
longer  in  yielding  to  its  influence,  than  any  other  nationality. 
The  behavior  of  Americans  is  similar  to  that  of  the  Irish  ; 
they  possess  great  power  of  resistance,  but  yield  to  the  influ- 
ence of  the  anaesthetic  with  more  ease  and  take  less  of  it. 
Germans  require  still  less;  and  it  is  not  an  uncommon  occur- 
rence to  see  them  become  anaesthetized,  without  a  struggle.  If 
any  demonstration  is  made,  it  is  usually  in  the  form  of  rapid 
conversation,  or  a  song.  The  negro  is  more  easily  influenced 
than  any  of  the  before-mentioned  races,  and  in  many  instances 
sing,  and  pray,  while  inhaling  the  anaesthetic. 

Dr.  A.  W.  Calhoun,  Atlanta,  Ga.,  writes,  that  recent  expe- 
rience has  taught  him,  that  it  is  perfectly  safe  and  oftentimes 
very  desirable  to  give  chloroform,  at  least  to  the  extent  of 
enabling  you  to  begin  the  operation  without  resistance  on  the 
part  of  the  patient.  There  may  be  something  in  the  difference 
in  the  boiling-point  of  chloroform  in  the  South,  and  in  the 
fact  of  the  air  being  more  stimulating  and  heated. 

Is    Cliloroform    a    Perfectly  Safe    Anaesthetic    for 
Cliildren  ? 

It  has  been  found  that  no  anaesthetic  is  perfectly  safe,  under 
all  circumstances,  and  in  all  conditions  of  health,  or  the  pecu- 
liar environment  of  individuals.  Children  are  no  exception  to 
this  general  rule.  Healthy  and  well-nourished  children,  in  well- 
ventilated,  and  sanitary  homes,  and  hospitals,  can  inhale  chloro- 
form as  an  anaesthetic,  with  comparative  safety.  Those  of 
delicate  organizations,  or  subject  to  constitutional  diseases,  in 
which  the  lungs,  brain,  or  abdominal  organs  are  impaired,  in 
their  action  or  functions,  are  not  fit  subjects  for  any  general 
anaesthetic,  but  should  be  treated  by  a  local  one,  or  when 
this  cannot  be  possible,  then  it  is  safer,  and  better,  to  exhibit 
nitrous  oxide,  hydrobromic  ether,  or  an  alcoholic  mixture  of 
chloroform.  What  are  the  objections  to  the  ethers,  or  their 
mixtures,  in  such  operations  as  laryngotomy,  thyrothotomy,  or 
on  any  part  of  the  throat?  It  is  the  great  and  uniform  tendency 


400  ARTIFICIAL  ANAESTHESIA. 

to  the  eliminatioti  of  liirge  quantities  of  mucus,  which  is  apt  to 
interfere  with  the  operation,  and  in  some  instances  with  the  ac- 
tion of  the  lungs,  and  the  depressing  effects,  after  two  cases  of 
death  from  chloroform  were  reported  after  such  operations  in 
the  section  of  otology  of  the  B.  Medical  Association  in  Glas- 
gow, 1888. 

The  following,  is  an  interesting  case  of  the  depressing  eflfects 
of  chloroform,  which  has  been  reported  in  the  London  Lancet, 
of  April  4th,  1888:  "A  recent  inquest  was  held  by  A. 
Braxton  Hicks,  the  coroner  of  London,  upon  the  body  of  an 
infant  who  died  from  chloroform  in  one  of  the  large  London 
hospitals.  The  child,  aged  five  months,  was  operated  upon 
for  the  removal  of  a  nsevus,  and  died  from  the  effects  of  the 
chloroform,  after  the  operation  had  been  completed.''  In  this 
case  there  was  no  good  reason  why  so  powerful  a  general 
auresthetic  need  have  been  employed,  when  we  have  now  so 
valuable,  and  safe  a  local  antesthetic,  as  cocaine,  or  even  ether, 
rhigolene,  or  cold,  in  form  of  an  ice  mixture.  When  a  general 
anaesthetic  is  imperatively  required,  nitrous  oxide  alone,  or 
combined  subsequently  with  ether,  can  better  be  employed. 

The  following  letters  give  an  account  of  an  interesting  case 
of  chloroform  narcosis,  which  was  successfully  treated  by  Dr. 
F.  C.  Hotz,  of  Chicago,  111. 

Chicago,  III.,  March  15,  1879. 

Dear  Doctor; — Knowiag  that  any  accident  occurring  during  anses- 
thesia  is  of  great  interest  for  you,  1  will  communicate  to  you  the 
following  observation  which  I  must  say  was  something  new  to  me, 
and  for  which  I  have  no  explanation.  If  you  have  any  suggestion  to 
offer,  I  shall  be  greatly  obliged  to  you. 

On  February  2J:lh,  3  o'clock  p.m.,  Thomas  Jones,  aged  8  years, 
came  to  the  Illinois  Charitable  Eye  and  Ear  Infirmary,  to  have  the  ope- 
ration for  convergent  strabismus  performed  on  his  eyes.  His  mother 
was  with  him,  and  informed  me  that  he  had  taken  no  food  since 
breakfast  (for  at  a  previous  visit  I  had  told  her  not  to  give  the  boy 
any  dinner  on  the  day  of  the  operation).  The  boy  was  so  glad  to  get 
rid  of  his  disfigurement  that  he  did  not  struggle  the  least  when  he 
■was  put  on  the  operating  table  and  chloroform  was  administered.  It 
was  sprinkled  on  the  strips  of  an  Allis'  inhaler. 


IS   CHLOEOFOEM   SAFE   FOE   CHILDEF.N  ?  401 

As  soon  as  the  boy  ■was  anajsthetized — and  it  did  not  take  more 
tlian  two  to  three  minutes — the  apparatus  was  removed  and  never 
applied  again.  The  right  eye  was  first  operated  on ;  all  this  time 
pulse,  and  respiration,  and  color  of  the  face,  were  good.  I  put  the 
spring  speculum  in  the  left  eye,  pinched  up  a  conjunctival  fold  and 
was  just  going  to  cut  into  it,  when  I  noticed  that  hiccoughing  respi- 
ration, which  generally  precedes  vomiting.  Thinking  the  boy  was 
going  to  vomit,  I  laid  down  my  instruments.  But  just  then  the  boy's 
face  became  (fairly  black)  very  livid  ;  respiration  ceased,  although  the 
tongue  was  held  out,  and  the  pupil  suddenly  became  fully  dilated  and 
immovable.  The  foot  end  of  the  table  was  raised  at  once,  while  I  ex- 
ecuted artificial  respiration  by  methodical  compression  of  chest  or 
abdomen. 

I  am  glad  to  say  that  after  a  few  minutes  the  boy  recovered,  but 
when  he  began  breathing  it  had,  for  a  few  seconds,  the  same  hic- 
coughing character.     He  did  not  vomit  afterwards. 

I  can  assure  you.  Doctor,  that  I  cannot  describe  the  anxiety  with 
which  1  watched  the  pupils,  and  how  happy  I  was  when  I  saw  them 
contract  again. 

Now,  what  was  it?  Yours  very  truly, 

F.  C.  HoTZ. 

Chicago,  III.,  March  27,  1879. 

Dear  Doctor: — Thanks  for  your  letter,  which  I  read  with  great 
interest.  You  are  right  in  supposing  that  I  considered  chloreform 
as  safe  as  ether  in  children.  This  has  always  been  my  opinion.  My 
chloroform  was  pure ;  I  tested  it  as  you  suggested ;  and  we  keep  it 
protected  against  the  sunlight. 

But  pardon  me,  Doctor,  if  I  return  once  more  to  my  case.  What  I 
wished  to  find  out,  was  the  probable  cause  of  the  asphyxia  occurring 
so  late.  Remember  the  patient  had  not  received  any  chloroform  after 
he  was  once  anassthetized.  It  was  removed  out  of  his  neighborhood  ; 
his  anaesthesia  was  not  too  profound ;  and  yet  at  a  time  when  you 
expect  the  patient  will  come  out  of  the  narcosis,  the  asphyxia,  with 
dilatation  and  immobility  of  the  pupil,  occurred.  That's  what 
puzzles  me. 

I  have  not  tried  the  hydrobromic  ether  ;  but  I  shall  employ  it  to 
see  how  1  like  it  compared  with  sulphuric.  Again  thanking  you  for 
your  kindness,  I  am  yours  very  truly, 

F.  C.  HoTZ. 


402  ARTIFICIAL,  ANiESTHESIA; 


Deaths  from  Chloroform. 

A  friend,  on  reading  this  letter,  wrote  me  a  brief  account  of 
the  following  case : 

"A  young  girl,  perhaps  13  years,  was  operated  upon  by  Prof. 
Jaeger,  of  Vienna,  for  some  trifling  eye  defect.  The  operation  lasted 
but  a  few  minutes,  and  was  done  under  chloroform.  A  bandage  was 
applied  and  the  patient  put  to  bed,  already  partly  conscious,  when 
a  few  minutes  later  defective  breathing,  and  blueness  of  skin  was 
noticed.  Artificial  respiration  and  various  agents  for  restoring  con- 
sciousness were  in  vaiu  employed,  aud  finally  a  tracheotomy  was 
done  by  Dr.  Gussenbauer,  and  artificial  respiration  carried  on  by 
means  of  a  bellows  through  the  canula,  but  with  no  effect.  The  child 
was  probably  dead  at  the  time  the  operation  on  the  trachea  was 
performed.     Post-mortem  revealed  nothing  satisfactory." 

Chloroformed  to  Death. — In  Cincinnati,  September  4th,  1889, 
George  Dilhof  died  while  under  the  influence  of  chloroform  admin- 
istered for  the  purpose  of  making  a  surgical  operation.  Dilhof  had 
injured  his  thumb  so  that  amputation  was  necessary.  Doctors  Mus- 
sey  and  Evans  gave  him  a  teaspoonful  of  chloroform,  and  were  pro- 
ceeding with  the  operation  when  they  found  him  in  convulsions.  They 
immediately  tried  remedies,  but  were  unsuccessful.  Mr.  Dilhof  was 
a  young  married  man. 

This  is  the  class  of  cases  in  which  a  four  per  cent,  solution 
of  cocaine  should  be  employed.  This  should  be  injected  into 
the  sound  tissue  near  to  the  place  selected  for  the  amputation. 
Not  more  than  from  fifty  to  sixty  drops  should  be  introduced, 
after  the  tourniquet  has  been  applied.  To  prevent  the  cocaine 
from  entering  the  system  too  rapidly  after  the  operation,  the 
tourniquet  is  relaxed  gradually.  If  there  is  an  open  wound  or 
sinus  the  solution  can  be  thus  introduced.  By  these  means, 
such  sudden  deaths  by  chloroform  from  trifling  operations  can 
be  avoided.  We  have  been  informed  that  occasionally,  after 
surgical  operations,  union  by  first  intention  will  not  always 
follow  the  use  of  the  cocaine,  and  that  in  two  cases — one  re- 
ported, the  other  verbal — limited  gangrene  occurred  in  the 
removal  of  the  toe  nail. 


MACLEOD   ON   CHLOEOFORM.  403 


Chlorofonn. 

While  attending  the  meeting  of  the  British  Medical  Associa- 
tion at  Glasgow,  in  August,  1888,  we  listened  to  an  historical 
address  "On  the  Progress  of  Surgery  during  the  last  Half- 
Century,"  by  Sir  George  H.  B,  Macleod,  M.D.,  Regius  Pro- 
fessor of  Surgery  in  the  University  of  Glasgow,  in  which 
address,  he  made  the  following  remarks  in  his  review  of  the 
period  (1837  to  1887),  in  regard  to  anaesthetics  : 

"Chloroform* — Local  Anesthesia. — I,  myself,  after 
fairly  trying  most  of  the  agents  in  use,  now  exclusively  employ 
chloroform,  and  having  for  years  kept  an  accurate  record  of 
its  administration,  and  given  it  freely  and  without  stint  in 
all  sorts  of  surgical  proceedings,  never  refusing  its  benefits  to 
a  single  patient,  no  matter  what  his  condition  or  the  operation 
to  be  performed,  I  have  never  had  an  accident  except  once, 
when  an  epileptic  took  a  fit  while  being  put  under  its  influence, 
and  died  with  a  full  and  fixed  chest. 

"  For  speed  and  energy,  for  ease  of  application  and  agreeable- 
ness,  for  rapid  recovery,  with  little  subsequent  trouble,  and  for 
safety  when  properly  administered,  chloroform  is,  in  my  opinion, 
unrivaled. 

"  That  it  needs  no  apparatus,  but  a  towel,  is  a  great  point  in 
its  favor. 

"  I  never  measure  the  quantity  used,  but  exhibit  it  freely, 
and  take  the  color  of  the  lips  and  the  respiration  as  my  chief 
guides. 

"  Making  the  patient  count,  at  the  beginning  of  the  adminis- 
tration, is  a  most  valuable  aid;  and  Nelaton's  inversion  of  the 
body,  with  artificial  respiration,  is,  I  think,  the  surest  mode  of 
resuscitation  in  danger  from  failure  of  the  heart. 

"  A  minute,  is  about  the  average  period  for  inducing  insensi- 
bility, and  it  is  very  rare,  if  proper  precautions  are  taken  in 
the  way  of  preparation,  and  after-management,  to  have  any 
sickness. 

"  There  is  little  doubt  that  '  nervous  '  persons  and  those  who 

♦Abstract  of  Address  on  Surgery,  British  Medical  Association,  August,  1888. 


404  ARTIFICIAL   ANAESTHESIA. 

are  intemperate  in  the  use  of  alcohol,  tobacco  and  narcotics, 
and  also  epileptics,  require  special  care. 

"  Over-saturation  from  the  too  frequent  renewal  of  chloroform, 
induces,  in  my  opinion,  the  chief  after-trouble.'' 

This  is  the  record  of  one,  who  has  administered  it  constantly 
almost  from  the  time  of  its  introduction  into  practice,  and  the 
statement  in  this  sense,  may  not  be  without  its  value. 

"  Local  Ancesthesia. — Local  anaesthesia,  in  its  present  form,  is 
also  a  conquest  of  the  last  half-century,  and  though  many 
agents  possess  this  power,  and  some  of  them,  like  cocaine,  are 
specially  valuable  for  particular  purposes,  the  finely-divided 
ether  spray  introduced  by  Dr.  Richardson,  (a  distinguished 
student  of  the  Glasgow  School)  in  186S,  is  more  efficient,  and 
easy  of  application,  than  any  other,  for  practical  purposes. 

"Finally,  as  regards  this  point,  I  may  note  that  Braid,  of 
Manchester,  who  published  in  1843,  an  article  on  hypnotism, 
caused  much  interest  in  a  system  which  had  been  largely  tried 
in  India,  but  which  has  now  fallen  entirely  out  of  use. 

"I  need  hardly  say  that  ancesthesia  has  changed  the  whole 
face  of  surgery.  The  'lion-heart'  is  no  longer  the  requisite 
of  a  surgeon. 

"  Finesse,  and  manipulative  skill,  now  take  the  place  of  force. 
Innumerable  operations  are  rendered  possible,  which  could 
not  before  be  attempted,  and  the  surgeon  has  benefited  almost 
as  much  as  his  patient." 

Our  only  remark  upon  this  paper,  is  to  state  that  this  sur- 
geon has  been  unusually  fortunate.  No  one  reading  the  number 
of  deaths  from  this  agent  in  the  hands  of  the  most  careful 
operator  in  England,  Ireland,  Scotland  and  the  United  States, 
should,  we  think,  advise  this  agent  in  all  kinds  of  operations, 
■without  giving  a  word  of  caution  to  the  young  and  inexperi- 
enced surgeon.  It  was  somewhat  remarkable  that,  a  iew  days 
after  this  lecture,  we  met  a  lady  in  Dumbarton  who  stated  that 
on  undergoing  an  operation  by  the  same  surgeon,  he  had  great 
difficulty  in  saving  her  life,  owing  to  the  chloroform  em- 
ployed. 


VOMITING   FROM   ANESTHETICS.  405 


Have  we  any  Means  of  Preventing?  Excessive  Vom- 
iting-, After  the  Use  of  Anaesthetics  like 
Etlier,    or    Chloroform,    in   Abdom- 
inal, or  Other  Prolonged  Op- 
erations ? 

Means  Employed  Before  the  Operation. — A  very- 
light  meal  of  toast,  and  tea,  at  least  three  hours  before ; 
no  coifee,  chocolate,  or  any  malt  beverages ;  no  meats  of 
any  kind,  or  vegetables,  such  as  potatoes,  which  are  so  apt  to 
be  heavy. 

Means  to  be  Employed  After  the  Operation. — No 
liquids,  or  food,  to  be  given  immediately  after.  If  a 
cooling  agent  be  required,  small  portions  of  ice  given,  not  too 
frequently  ;  no  coffee,  or  tea,  for  several  hours  after.  A  small 
quantity  of  lime  water,  with  or  without  carbolic  acid,  four 
drops  to  two  ounce  mixtures  of  champagne,  or  apolliaaris 
water  should  then  be  given  if  there  is  a  disposition  to  nausea 
or  retching,  or  the  one-sixth  of  a  grain  of  the  hydrochlorate  of 
cocaine,  in  powder,  placed  on  the  tongue.  After  the  act  of 
vomiting,  if  all  these  means  fail,  and  the  patient  is  still  disposed 
to  vomit,  and  very  restless,  a  hypodermic  injection  of  morphia 
sulphas  }  grain  with  jlo  of  a  grain  of  atropine,  will  cause 
sleep,  after  which,  all  the  disagreeable  symptoms  usually  dis- 
appear. 

In  the  use  of  anaesthetics  in  abdominal  operations.  Dr.  I. 
Taber  Johnston,  of  Washington,  D.  C,  prefers  the  early  part 
of  the  day — before  9  a.m.  where  possible — and  upon  nearly  an 
empty  stomach.  He  never  allows  any  solid  food,  within  at 
least  four  hours  after  operation. 

After  an  abdominal  operation,  if  there  is  "  ether  vomiting," 
he  gives  nothing  in  the  way  of  medicine,  or  food ,  for  at  least 
two  days ;  if  food  is  then  required,  he  gives  it  by  enema. 

This  is  simply  his  own  experience,  after  many  trials  and 
much  experience,  of  which  method  is  best ;  communicated  to 
the  author,  in  conversation. 


406  ARTIFICIAT.  ANAESTHESIA. 


The  Clioice  of  General  Anaesthetics  in  Surgery  and 
Obstetrics.* 

"  Beginning  with  a  denial  of  the  common  statement,  that  the 
use  of  any  ana?sthetic,  lessens  the  success  of  operative  surgery, 
Dr.  McGuire,  mentioned  that  chloroform  is  the  popular  ana3s- 
thetic  used  in  France,  {except  in  Lyons),  Germany  (except  in 
Vienna),  and  in  Italy.  In  Great  Britain,  mixtures  of  ether, 
and  chloroform  are  principally  used.  In  China,  chloroform  is 
chiefly  used.  In  the  United  States,  ether  is  the  popular 
agent,  throughout  the  Northern,  and  Northwestern  States, 
while  chloroform  is  the  generally  adopted  ana?sthetic  of  the 
Southern,  and  Southwestern  States.  Thus  it  will  be  seen,  that 
throughout  the  civilized  world,  chloroform  is  much  more  gen- 
erally used  than  ether.  Combining  the  obstetrical  cases,  in 
which  anaesthetics  are  used  with  the  surgical,  it  may  be  safely 
estimated,  that  chloroform  is  used  twenty  times  as  often  as 
ether,  as  the  anaesthetic — the  two  agents  to  which  he  restricted 
his  paper.  He  predicted  that  when  a  full  analysis  of  all  the 
facts  is  finally  made,  in  certain  cases  it  will  be  determined  that 
ether  should  be  given,  and  chloroform  in  certain  other  cases — 
thus,  establishing  the  special  value  of  both.  In  general 
terms,  in  the  feeble,  or  anfemic,or  in  those  prostrated  by  shock, 
or  loss  of  blood,  he  prefers  ether ;  but  when  there  is  cardiac, 
renal,  or  pulmonary  trouble,  chloroform  is  preferable.  Up  to 
the  present  time,  between  400,  and  500  deaths  from  chloroform 
have  been  reported,  and  about  100  deaths  from  ether ;  but  he 
was  unable  to  say  what  the  ratio  of  deaths  by  either  agent  is 
to  the  total  number  of  administrations.  Sphygmographic 
tracings  during  chloroform  anaesthesia  show  depression  of  the 
circulation ;  this  is  only  occasional,  and  then  not  so  marked 
when  ether  is  given.  Hence,  cardiac  paralysis  is  more  likely 
to  follow  the  use  of  chloroform.  But  experience  proves,  that 
when  chloroform  is  withdrawn,  and   consciousness  returns,  the 

♦Abstract  of  a  paper  read  before  the  Medical  Society  of  Virginia,  October  19,1887, 
by  Hunter  McGuire,  M.D.,  of  llicbniond,  Va.,  taken  from  the  journal  American 
Medical  Association,  November  12, 1887. 


SELECTING   AN   ANiESTHETIC.  407 

patient  is  safe.  But  this  is  not  the  case  after  ether  is  with- 
drawn. Even  acute  nephritis  or  pneumonia  occurs  sometimes 
as  the  result  of  the  use  of  ether.  In  short,  in  diseases  of  the 
kidneys,  or  lungs,  ether  is  more  dangerous.  But  both  may  kill 
— especially  chloroform,  by  using  a  too  concentrated  vapor 
during  the  period  of  muscular  excitement,  by  paralysis  of  the 
respiratory  nervous  centres. 

"  In  selecting  an  anaesthetic,  Dr.  McGuire  is  somewhat  gov- 
erned by  the  character  of  the  assistant  who  is  to  administer  it. 
In  inexperienced  hands,  ether  is  the  safer.  To  give  chloro- 
form, requires  one  who  knows,  and  will  attend,  to  his  business 
alone.  One  accustomed  to  give  ether  is  not  usually  the  one  to 
select  to  give  chloroform.  To  ask  a  patient  to  take  long,  deep 
or  rapid  inhalations  of  chloroform  vapor,  is  dangerous.  The 
greatest  danger  from  this  agent  is  in  the  early  stage  of  its  ad- 
ministration, when,  by  a  too  concentrated  vapor,  or  its  too 
rapid  use,  the  heart  centres  may  be  surprised,  and  over- 
whelmed. When  using  chloroform,  it  is  safer  to  let  the  pa- 
tient's head  be  turned  to  one  side,  so  as  not  to  let  the  concen- 
trated vapor — being  four  times  heavier  than  air — exclude  the 
atmospheric  air.  Begin  with  a  small  quantity,  allow  plenty 
of  fresh  air,  and  gradually  accustom  the  patient  to  the  vapor. 
Never  give  chloroform  in  a  hurry. 

"  The  giving  of  alcohol  as  a  heart  stimulant,  just  before  giv- 
ing chloroform,  is  open  to  serious  objections.  In  the  first 
place,  who  knows  what  the  stimulant  dose  is,  in  individual 
cases?  In  the  next  place,  alcohol  increases  the  duration  and 
stage  of  excitement,  and  makes  nausea,  etc.,  more  likely  to 
occur.  We  all  agree,  that  those  addicted  to  the  free  use  of 
liquor,  are  bad  subjects  for  anaesthetics. 

"  The  speaker  mentioned  a  recent  publication,  by  an  eminent 
New  York  surgeon,  advocating  the  giving  of  a  very  small 
dose  of  chloroform  in  concentrated  vapor,  on  the  ground  that 
if  alarming  symptoms  set  in,  this  amount  could  be  speedily 
pumped  out  of  the  lungs  by  artificial  respiration.  This  is 
dangerous  doctrine  to  teach.  In  the  only  fatal  case  by  chloro- 
form coming  under  his  observation,  the  heart  stopped  suddenly- 
The  heart  did  not  previously  flutter,  grow  weak  or  intermit, 


408  ARTIFICIAL   ANAESTHESIA. 

but  abruptly  ceased.  It  was  like  the  syncope  of  concussion  of 
the  brain;  the  contractile  power  of  the  heart  was  annihilated. 
We  may  remove  by  artificial  respiration,  in  such  a  case,  all  of 
the  vapor;  but  we  cannot  in  this  way  remove  the  impression 
made  on  the  nerve  centres  which  stopped  that  heart's  action. 

"Although  frequently  taught,  we  are  apt  to  forget,  that  we 
should  never  operate  during  partial  anaesthesia.  Many  deaths 
from  chloroform  are  due  to  not  heeding  this  advice,  that  comes 
of  experience.  Fatal  syncope  may  come  on  from  the  con- 
sciousness that  the  painful  operation  is  yet  to  follow  ;  or  if  in- 
tellectual consciousness  is  just  lost,  there  seems  to  be  left,  so 
to  speak,  a  consciousness  in  the  nerve  centres  of  the  heart 
and  lungs,  and  the  impression  of  pain  on  them  is  fatal. 
Ether  is  safe,  when  an  operation  is  to  be  performed  under  par- 
tial unconsciousness.  In  operations  in  which  blood  or  other 
fluids  may  escape  into  the  windpipe,  chloroform  is  the  safer. 
Dr.  McGuire  does  not  think  he  ever  saw  the  irritability  of  the 
larynx,  or  trachea,  entirely  lost  in  chloroform  anaesthesia,  but 
he  has  seen  it  in  ether  ansesthesia.  Possibly  the  cold  vapor 
of  the  ether  may  in  a  measure  account  for  this  loss  of  reflex 
excitability  in  the  throat. 

"In  organic  heart  diseases,  he  has  never  had  occasion  to  re- 
gret the  choice  of  chloroform ;  but  ether  is  preferable  in  a 
nervously  weak  heart,  as  also  in  cases  of  weakness  from  fatty 
degeneration,  or  loss  of  blood,  or  great  anaemia  from  other 
causes,  etc.  In  such  cases  any  anajsthetic  is  hazardous,  but 
ether  is  safer. 

"  Of  all  the  elements  of  danger  from  chloroform,  fear  on  the 
part  of  the  patient,  he  believes  to  be  the  most  important,  and 
the  most  frequent.  The  heart  becomes  nervously  weak.  If  a 
calm,  confident  manner  on  the  part  of  the  administrator  does 
not  allay  this  fear,  give  hypodermically  a  quarter  of  a  grain 
of  morphia  sulphate,  with  a  one-hundredth  of  a  grain  of 
atropia  sulphate,  and  wait  fifteen  minutes  or  so  for  the  physio, 
logical  results,  before  giving  the  anaesthetic.  Emotional  ex- 
citement, greatly  increases  the  chances  of  paralysis  of  the  nerve 
centres  presiding  over  the  circulation.  Morphia  obtunds  this 
sensibility  and  also  acts  as  a  cardiac  stimulant,  and  atropia  is 


McGUIRE  ON  CHLOROFORM.  409 

probably  a  more  powerful  stimulant.  That  emotional  excite- 
ment is  an  important  element  of  danger,  be  believes  all  ad- 
ministrators will  admit. 

"Children  take  chloroform  well  and  safely.  They  are  not 
afraid  of  being  killed  by  it.  Nussbaum  has  seen  40,000  ad- 
ministrations of  chloroform  in  military  life,  without  an  acci- 
dent. Dr.  McGuire,  has  seen,  as  medical  director  of  Stonewall 
Jackson's  Confederate  Army  Corps,  28,000  chloroform  admin- 
istrations without  causing  a  death.  Neither  the  age,  sex- 
health,  etc.,  of  the  soldiers  could  account  for  this.  The 
wounded  soldiers  dread  the  hazard  of  chloroform  very  little. 
It  is  also  significant  that  chloroform  has  been  given  to  hun- 
dreds of  thousands  of  women  in  labor,  with  but  one  fatal 
case,  so  far  as  he  has  learned  ;  and  in  this  instance  it  is  by  no 
means  certain  that  death  was  due  to  the  anaesthetic.  Even 
when  surgical  operations  have  been  required  in  obstetrical 
cases,  no  death  has  followed  the  use  of  chloroform.  The  re- 
cumbent position  does  not  explain  all  this  exemption,  nor  do 
the  pains  of  labor,  for  we  have  pain  from  the  surgeon's  knife, 
etc.  The  element  of  success  in  all  such  cases,  Dr.  McGuire 
believes  to  be  the  want  of  dread  of  chloroform. 

"  Dr.  McGuire  deplores  the  partisan  debates  which  have  oc- 
curred on  this  subject  of  the  choice  of  anaesthetics.  In  the 
last  text-book  on  surgery  issued  this  year,  is  the  following: 
*  In  general,  there  is  no  comparison  between  these  agents  ; 
ether  is  so  much  safer  than  chloroform,  that  the  latter  is  fast 
disappearing  in  practice.  The  estimated  death-rate  after 
ether  is  1  in  20,000;  in  chloroform,  1  in  3000.'  Such  state- 
ments are  the  outcome  of  prejudiced  brains,  and  are  abso- 
lutely unwarranted  by  any  facts  or  figures  known  to  the  pro- 
fession. 

"  Dr.  Thomas  E.  Evans,  of  Mt.  Carbon,  West  Va.,  arose, 
principally  to  say  a  word  for  the  country  doctor.  He  is 
usually  unable  to  carry  around  with  him  more  than  an  ounce 
or  so.  He  has  several  times  derived  the  desired  anesthesia  by 
giving  chloroform  internally  in  teaspoonful  doses.  This  dose 
will  sometimes  anaesthetize  for  several  hours  at  a  time,  and  by 
common  consent,  this  practice  seems  to  be  less  risky  to  the 
18 


410  ARTIFICIAL   ANiESTIIESIA. 

patient's  life.     lie  does  not  know  why  it  is  not  more  generally 
adopted. 

"  Dr.  Wra.  W.  Parker,  of  Eichmond,  Va.,  thinks  he  was  the 
first  doctor  in  this  State  to  use  chloroform,  after  its  announce- 
ment as  an  anaesthetic.  One  of  his  patients,  years  ago,  had  got 
in  the  habit  of  using  it  to  such  an  extent  as  to  use  $3,000 
worth  in  three  years'  time,  and  finally  died  from  it.  Properly 
given,  he  thinks  chloroform  the  safer  of  the  two  anaesthetics. 
It  should  not  be  given  from  a  cone,  or  buttoned  shirt  cuff,  or 
anything  else  of  the  kind.  The  safe  way  of  administering  it. 
is  for  the  patient  to  lie  down,  with  clothing  perfectly  loose, 
using  an  open  napkin  or  a  suitably  shaped  sponge.  This 
is  to  be  moistened  with  a  few  drops  of  chloroform,  as  often  as 
it  evaporates,  and  held  three  or  four  inches  above  the  nose 
and  mouth.  In  this  way,  all  danger  of  not  having  enough 
fresh  air  is  avoided,  and  the  patient  is  not  overwhelmed,  so  to 
speak.  Exercise  a  little  patience,  and  all  will  go  well.  In 
this  way,  on  one  occasion,  he  gave  chloroform  almost  continu- 
ally, night  and  day,  for  three  Aveeks,  without  an  alarming  or  a 
threatening  symptom." 

Deatlis  from  Clilorofonii. 

In  the  discussion  which  followed  the  reading  of  the  paper 
of  Dr.  McGuire,  of  Richmond,  the  following  cases  of  death 
from  chloroform  were  reported : 

"  On  invitation  by  the  President,  Dr.  William  A.  Hammond, 
of  New  York,  he  said  that  while  listening  to  the  paper  of  Dr. 
McGuire,  he  felt  that  he  was  sitting  at  the  feet  of  a  master. 
And  yet,  as  he  had  had  experience  with  both  ether,  and  chloro- 
form, especially  while  a  surgeon  in  the  U.  S.  army  years  ago, 
he  felt,  that  he  had  a  right  to  an  opinion  on  the  subject  under 
discussion,  which  he  would  take  the  liberty  of  expressing. 

"He  had  been  one  of  the  unfortunates  who  had  witnessed 
two  deaths  from  the  surgical  use  of  chloroform.  His  first  fatal 
case,  occurred  about  thirty-five  years  ago,  while  he  was  serving 
aa  an  assistant  surgeon  in  the  U.  S.  army,  out  on  the  frontiers. 
A  dragoon  had  been  drunk,  and  had  very  seriously  hurt  his 


POST-MOETEM,   DEATH   FEOM   CHLOEOFORM.     411 

arm.  -He  did  not  see  the  dragoon,  until  about  two  weeks  after- 
wa;rds.  He  then  undertook  to  examine  the  injury,  by  first 
placing  the  patient  under  chloroform.  Just  as  he  was  getting 
under  the  influence  of  the  anaesthetic,  the  dragoon  died 
suddenly. 

"  Previous  to  the  administration,  there  was  nothing  to  indicate 
that  he  could  not  take  chloroform.  But  upon  post-mortem 
examination,  when  his  heart  was  taken  out,  and  cut  up  into 
minute  sections,  and  placed  under  the  microscope,  that  organ 
was  found  to  be  undergoing  fatty  degeneration.  This  condition 
could  not  have  been  recognized  by  the  naked  eye — it  required 
the  microscope  to  detect  it.  Nor  was  the  morbid  condition 
sufficiently  far  advanced  to  allow  of  its  diagnosis  by  physical 
signs,  or  any  of  the  usual  symptoms  of  advanced  fatty  degenera- 
tion. There  is  no  way  known  to  him  by  which  such  cases  can 
be  foretold ;  and  yet  he  could  not  resist  the  conclusion,  that  the 
fatty  heart  was  the  cause  of  that  dragoon's  death.  There  was 
nothing  else  to  possibly  account  for  it.  The  case  was  reported 
at  the  time,  in  the  American  Journal  of  Medical  Sciences.  The 
chloroform  was  carefully  examined,  and  found  to  be  good. 

"  The  second  case  of  death,  by  chloroform,  under  his  obser- 
vation, occurred  in  Virginia.  Just  after  the  memorable  battle 
near  Fredericksburg,  during  the  late  war,  a  soldier  was  brought 
in,  who  needed  exsection  of  the  elbow.  The  circumstances  of 
the  battle  made  it  desirable  that  he  '  should  be  a  little  in  a 
hurry.'  Just  as  he  was  picking  up  his  knife  to  begin  the 
operation,  the  soldier  died  suddenly — without  a  moment's 
warning,  exactly  as  Dr.  McGuire  had  described  his  case  as 
dying.  Since  then  he  has  not  used  chloroform  much,  but  has 
adopted  ether  in  preference.  Whether  he  had  had  remote 
deaths,  or  not,  from  the  use  of  ether,  he  does  not  pretend  to  say 
— especially  after  what  Dr.  McGuire  has  said  about  the  more 
than  possible  after-effects  of  its  administration.  But  this,  he 
has  to  say,  that  he  has  never  been  horrified  by  a  sudden  death 
while  using  it.  In  fact,  he  does  not  think  that  he  has  ever 
had  any  bad  effects  from  the  use  of  ether.  He  wishes  he 
thought  chloroform  as  safe  to  use  as  ether,  for  undoubtedly 
chloroform  is  much  more  agreeable,  both  to  the  patient  and 


412  ARTIFICIAL   ANAESTHESIA. 

administrator.  He  wishes  he  could  make  more  emphatic  than 
Dr.  McGuire  has  already  done,  the  great  importance  of  not 
being  in  a  hurry,  when  about  to  give  chloroform.  For  army 
uses,  ether  he  thinks,  is  unquestionably  to  be  preferred. 

"As  to  how  these  anaesthetics  kill,  he  is  unable  to  satisfactorily 
explain.  Chloroform  undoubtedly  ki  lis  by  stopping  the  heart's 
action  in  the  majority  of  cases;  but  why,  he  does  not  know. 
As  to  ether,  its  immediate  dangers  are  so  much  less  than 
chloroform,  that  he  prefers  it.  As  to  the  after-effects  of  this 
agent,  Dr.  McGuire  is  most  probably  correct  in  saying,  that 
deaths  are  due  to  it,  that  are  not  attributed  to  it  in  the  mortuary 
tables. 

"As  to  the  prevalent  opinion,  about  the  immunity  of  children 
from  the  dangers  of  chloroform,  as  remarked  upon  by  Dr. 
McGuire,  Dr.  Rohe,  of  Baltimore,  quoted  from  authorities,  to 
show  that  about  one  in  ten,  of  all  deaths  from  chloroform,  occur 
in  children  under  12  years  of  age.  He  thought,  also,  that  Dr. 
McGuire's  statistics  could  stand  correction,  as  to  the  stage  of 
the  administration,  when  the  greatest  danger  presented.  He 
referred  to  authorities,  to  show  that  about  one-half  of  all  fatal 
cases  from  chloroform,  occurred  either  during  the  surgical 
operation,  or  else  immediately  afterwards.  He  believed  it  to  be 
good  doctrine  to  always  advise  the  administration  before-hand 
of  a  suitable  dose  of  atropia  with  morphia.  This  combination 
maintains  anaesthesia,  while,  at  the  same  time,  it  keeps  up  the 
activity  of  the  vaso-motor  centres.  He  agrees  with  Nussbaum, 
in  objecting  to  the  use  of  ether,  before  beginning  with  chloro- 
form. There  have  been  two  deaths  from  chloroform  in  Baltimore 
during  the  last  two  years.  He  has  given  ether,  in  the  manner 
that  Dr.  McGuire  opposes.  But  he  has  never  seen  the  depres- 
sing effects  upon  the  heart,  but  upon  the  respiratory  organs. 
To  sum  up,  he  believes  ether  safer  than  chloroform,  in  the  large 
majority  of  cases. 

"Dr.  J.  S.  Wellford,  of  Eichmond,  Va.,  said,  that  during  his 
service  as  surgeon  in  the  Confederate  army,  he  could  not  get 
ether  as  freely  as  he  wanted  it,  and  hence  had  to  use  chloro- 
form, and  one  death  came  under  his  observation.  That  death 
was  probably   due  to   methylated  chloroform,   received  from 


OBJECTIONS  TO  METHYLATED  CIILOEOFORM.     413 

England.  Methylated  chloroform  is  cheaper,  than  ethylated. 
The  purity  of  the  chloroform  is,  therefore,  a  very  important 
matter.  Anxiety  on  the  part  of  the  operator,  especially  if  he 
be  in  haste,  may  cause  him  to  overdo  the  matter  and  '  crowd ' 
the  chloroform  so  as  to  cause  suffocation.  Ether  is  safer  under 
such  circumstances,  because  it  contains  a  very  large  percentage 
of  oxygen.  Anstie,  has  shown,  that  air  containing  over  5  per 
cent,  of  chloroform,  is  dangerous.  Death  has  frequently  occurred 
before  commencing  the  operation,  after  the  administration  of 
chloroform.  Given  internally,  it  is  a  valuable  anaesthetic,  the 
full  virtues  of  which  use  have  not  been  sufficiently  dwelt  upon 
by  authors. 

"  Dr.  Chancellor,  said,  he  had  seen  one  death  under  the  use  of 
chloroform,  but  he  is  unwilling  to  testify,  whether  the  anaes- 
thetic, or  the  shock  of  injury,  killed  the  patient. 

"Dr.  W.  T.  Oppenheimer,  of  Richmond,  Va.,  remarked,  that 
all  cases  of  ether-deaths  are  by  no  means  recorded.  He  had 
witnessed  two  deaths  by  this  agent  in  New  York  City.  One  of 
the  cases,  was  in  the  practice  of  Dr.  Keith.  The  ether  was 
being  given  for  the  operation  of  excision  of  the  knee.  The 
other  case,  occurred  in  the  practice  of  Dr.  Bryant.  He  has 
since  adopted  chloroform,  and  prefers  it.  Chloroform  is 
specially  preferable,  if  there  is  hemorrhagic  diathesis.  In  fact, 
in  a  case  of  hemorrhage  from  the  lungs,  bleeding  was  several 
times  arrested  for  three  or  four  hours,  by  the  repeated  adminis- 
tration of  chloroform. 

"Dr.  McGuire,  in  closing  the  discussion,  said,  that  as  to  the 
dangerous  symptoms  that  have  been  observed  during  the 
administration  of  anaesthetics,  the  profession  agrees,  that  ether 
^is  not  so  safe,  in  diseases  of  the  kidneys.  He  had  not  under- 
taken the  task  of  writing  an  exhaustive  paper  on  the  subject, 
but  had  tried  to  confine  himself  chiefly  to  some  mooted  points, 
in  the  hope  of  getting  light  on  them.  He  fully  agrees  with 
Dr.  Wellford,  that  the  purity  of  the  agent,  whether  it  be  ether 
or  chloroform,  is  a  very  important  matter.  In  dentistry,  there 
are  two  causes  of  danger.  One,  is  the  upright,  or  only  half- 
reclining  position  in  the  chair,  and  the  other,  is  the  inclination 
of  the  dentist  to  pull  the  tooth  before  there  is  complete  anaes- 


414  ARTIFICIAL  ANAESTHESIA. 

thesia.  Mr.  Keith,  of  Edinburgh,  has  used  the  Clover  bag  for 
ether  administration  for  two  hours,  or  more,  at  a  time.  But 
such  a  bag  for  chloroform,  would  be  dangerous.  Dr.  D.  Hayes 
Agnew,  of  Philadelphia,  has  been  unfortunate  enough  to 
recently  add  another  to  the  death-list  from  ether ;  and  no  one 
who  knows  his  skill,  and  caution,  can  doubt  for  a  moment,  but 
that  the  ether  was  properly  given  by  him.  It  simply  illustrates 
that  anaesthetics  are  dangerous,  and  should  not  be  resorted  to 
without  sufficient  justification  for  the  use  of  such  powerful 
agents.  As  a  conclusion  from  his  study  of  the  subject,  he 
believes  that  one  anjesthetic  is  about  as  dangerous  as  the  other, 
and  that  each  should  be  selected  on  the  principle  of  the  special 
fitness  of  the  subject  for  one  or  the  other." 

"A  Very  Valuable  Lesson  for  Those  Who  Use  Anes- 
thetics ts  Children.* — R.  A.,  a  robust,  healthy  child,  three 
years  of  age,  was  recently  brought  to  me  with  a  cancerous  left 
eye.  The  attention  of  the  parents  was  first  called  to  the  yellow 
appearance  of  the  pupil  eighteen  months  before.  Theglioraatous 
mass,  filled  the  vitreous  cavity,  distending  the  pupil,  and  oblit- 
erating the  anterior  chamber.  The  eye  was  injected,  and  pain- 
ful. The  prompt  removal  of  the  eyeball  was  urged  as  the  only 
means  of  protecting  the  child  from  a  painful  death.  The 
operation  was  accepted  by  the  parents,  and  the  enucleation, 
under  chloroform,  accomplished  after  much  difficulty,  as  the 
sequel  will  show. 

"  The  child  was  suffering  from  a  bronchial  trouble,  but  that 
was  not  deemed  an  obstacle  to  the  administration  of  an  anaes- 
thetic. The  patient  was  placed  on  the  operating  table,  his 
clothing  loosened  about  the  neck  and  chest,  and  chloroform 
was  inhaled  from  a  towel,  folded  in  conical  form,  with  open 
top.     Deep  sleep  soon  was  induced. 

"When  the  antesthesia  was  complete,  the  operation  for  the 
removal  of  the  diseased  eye  was  commenced.  The  conjunctiva 
was  divided  around  the  cornea,  and  the  tendon  of  the  external 
rectus  muscle  was  being  sought  for,  when  resi^iration  suddenly 

*  Paper  read  before  the  Baltimore  Academy  of  Medicine,  December  6th,  1887,  by 
Julian  J.  Chisholm,  M.D.,  Baltimore,  Md. 


CHLOROFORM  IN  CHILDREN.  415 

ceased.  The  face  assumed  a  death-like  pallor,  and  the  pulse 
disappeared  at  the  same  time  from  the  wrist.  Immediately 
the  child  was  suspended  by  the  feet,  with  body  and  head 
hanging  down  at  an  inclination  of  seventy  degrees,  while  an 
assistant  volunteered  chest- compression  for  artificial  respira- 
tion. After  a  few  minutes,  signs  of  a  feeble  respiratory  move- 
ment were  noticed,  a  slight  throbbing  of  the  neck-vessels  was 
detected,  and,  in  time,  the  child  evinced  its  return  to  conscious- 
ness by  crying. 

"  He  was  laid  on  the  table,  but  would  not  permit  the  eye  to  be 
touched  without  a  twist  of  the  head,  evincing  great  irritability, 
or  sensitiveness  of  the  conjunctiva.  As  the  operation  had  to 
be  completed,  I  ordered  chloroform  to  be  again  administered. 
Chloroform  narcosis  was  very  soon  re-established,  but  before  I 
had  time  to  resume  the  operation,  the  child  again  stopped 
breathing  and  the  pulse  disappeared.  The  body,  apparently 
of  a  dead  child,  was  once  more  hung  up  by  the  feet,  so  as  to 
allow  blood  to  gravitate  toward  the  anaemic  head,  and  brain, 
but  with  no  further  attempts  at  artificial  respiration.  Myself 
and  four  assistants  watched  anxiously  the  pale  face,  to  catch 
the  first  evidence  of  returning  vitality.  After  some  minutes,  I 
noticed  that  the  large  vessels  at  the  root  of  the  neck  showed 
some  fulness;  then  a  slight  thrill,  and  after  this  the  first 
attempt  at  a  thoracic  movement  appeared.  In  ten  minutes, 
breathing  was  sufficiently  strong  to  allow  the  child  to  cry  again, 
much  to  the  relief  of  all  of  us. 

"  Still  the  operation,  which  was  so  imperatively  called  for,  for 
the  future  safety  of  the  child — even  the  saving  of  its  life,  from 
the  ravages  of  cancer — was  uncompleted.  While  the  father 
and  mother,  both  present  in  the  operating-room,  were  pleading 
for  their  child,  they  were  made  aware  by  the  restlessness  of  the 
patient  when  the  eye  was  touched,  that  nothing  could  be  done 
without  the  child  going  again  to  sleep ;  so  I  once  more  ordered 
the  inhalation  of  chloroform.  For  the  third  time  chloroform 
narcosis  was  promptly  established,  and  was  followed  very  soon 
afterward  by  suspended  respiration  and  the  disappearance  of 
the  pulse.  Death  now  seemed  to  be  complete.  Immediately 
the  child  was  hung  up  by  the  feet.    The  absolute  quiet  of  the 


416  ARTIFICIAL  ANAESTHESIA. 

operating-room  was  broken  only  by  the  lamentations  of  the 
parents.  All  eyes  watched  the  face  of  the  child.  Five  minutes 
eeeined  an  hour,  and  the  ashy  lips  showed,  so  far,  no  response. 
Soon  after  this  a  faint  eflbrt  at  respiration  was  observed,  which 
became  stronger  with  each  return  of  the  thoracic  movements, 
and  the  pulse  was  again  felt  feebly  at  the  wrist.  When  respi- 
ration seemed  established,  complete  insensibility  continuing,  I 
had  the  child  laid  upon  the  operating  table.  As  soon  as  the 
body  assumed  the  horizontal  position,  the  pulse,  not  yet  strong, 
disappeared  from  the  wrist,  and  the  respiration  ceased,  neces- 
sitating at  once  a  renewal  of  the  suspension.  This  curious 
phenomenon  of  breathing  when  suspended,  and  becoming  in- 
animate when  the  prone  position  was  too  early  assumed,  was 
repeated  two,  or  three  times,  respectively.  For  safety  (for  I  was 
afraid  to  lay  the  child  down),  I  was  forced  to  enucleate  the  eye 
while  the  child  was  suspended  with  the  head  downward — an 
awkward  position  for  operating.  It  was  some  time,  fully  a 
quarter  of  an  hour,  after  the  operation  was  completed  and  the 
eye  bandaged,  before  I  could  trust  the  child  in  the  recumbent 
posture. 

"  One  of  my  assistants  was  very  anxious  to  have  whiskey 
injected,  and  had  filled  his  hypodermic  syringe  for  that  pur- 
pose; but  I  declined  its  use,  trusting  to  inversion  alone  for 
resuscitation.  The  final  successful  issue  of  this  case  con- 
firmed my  faith  in  this  invaluable  method,  which  I  had  used 
successfully  on  former  occasions,  and  hence  confided  in  it  for 
the  protection  of  the  patient,  through  the  trying  ordeal.  In  all, 
the  child  must  have  been  suspended  in  the  inverted  position 
for  fully  three-qixarters  of  an  hour.  After  the  last  suspension, 
no  further  trouble  ensued.  The  next  day  the  child  was  so 
thoroughly  himself,  that  he  left  the  hospital  with  his  parents. 
He  was  brought  back  to  the  dispensary  for  inspection,  two 
days  afterward,  a  picture  of  health. 

"This  case  cannot  be  too  carefully  studied  by  surgeons,  who 
must  continue  to  use  general  ansesthetics.  It  is  one  of  a  series 
occurring  to  me,  now  and  then,  (I  am  glad  to  say  at  long  inter- 
vals), as  the  consequence  of  chloroform  inhalation. 

"A  gentleman  brought  to  me  his  two  boys,  one  eight,  the  other 


CASES  OF  SUDDEN  AEREST  OF  RESPIRATION.     417 

six  years  of  age,  both  subjects  for  squint-operation.  Such 
operations,  I  frequently  perform  at  my  office  with  the  aid  of  one 
professional  assistant.  The  elder  boy  was  put  to  sleep  under 
chloroform,  the  tenotomy  of  the  rectus  completed,  without 
trouble,  and  he  was  laid  upon  a  lounge,  vacating  my  reclining 
operating-chair,  for  the  younger  boy.  He  also  bore  chloroform 
apparently,  as  well  as  his  elder  brother,  and  under  its  narcotic 
influence  the  squint-operation  was  speedily  completed.  After 
I  had  removed  the  eye-speculum,  and  cleansed  the  conjunctival 
sac  of  blood,  respiration  suddenly  stopped,  the  pulse  disappear- 
ing from  the  wrist,  and  accompanied  by  the  death-like  appear- 
ances which  belong  to  this  startling  condition.  Fortunately, 
I  was  sitting  at  the  head  of  the  patient,  and  I  immediately 
tilted  down  my  end  of  the  operating-chair,  getting  my  assistant 
to  elevate  the  foot-end,  so  as  to  secure  an  inclination  of  forty- 
five  degrees,  with  the  head  of  patient  downward.  After  a  few 
minutes  blood  gravitated  into  the  head.  By  stimulating  the 
nerve-centres,  it  started  into  action  those  organs  so  essential  to 
life.  Breathing  was  finally  re-established,  and  with  it  the  cir- 
culation. 

"  In  four  cases  of  sudden  arrest  of  the  respiratory  functions, 
■with  failure  of  heart's  action,  during  chloroform  narcosis, 
occurring  in  my  own  individual  practice,  I  feel  assured  that 
most  of  these  patients  would  have  died,  had  they  been  left  in 
the  recumbent  posture,  regardless  of  what  may  have  been  done 
otherwise,  for  their  restoration.  Fanning,  fresh  air,  water- 
splashing,  spanking,  whiskey,  or  ether  injections,  electricity, 
artificial  respiration — all  of  them,  the  remedies  which  physi- 
cians rely  upon — go  for  very  little,  provided  the  patient  be  left 
supine.  General  experience,  unfortunately,  has  too  often 
shown  this.  In  my  experience  with  chloroform,  in  cases  of 
suspended  animation,  all  of  these  means  for  resuscitation  are 
useless,  unless  the  patient  be  hung  up  by  the  feet  without 
any  loss  of  time,  so  that  blood  may  flow  to  the  anaemic  head, 
and  heart,  and  stimulate  the  nerve-centres  before  the  vital 
spark  goes  altogether  out.  A  fire  cannot  be  rekindled  by  add- 
ing fuel,  if  there  be  no  live  coals  in  the  grate.  Fortunately, 
suspension  of  the  body  needs  no  preparation,  nor  apparatus,  for 

18^ 


418  ARTIFICIAL   ANiESTDESIA. 

its  immediate  application.  It  only  needs  vigilance  on  the  part 
of  the  operator.  Should  fright  make  him  forget  his  duty,  then 
precious  minutes  are  lost  in  trying  useless  remedies,  and  these 
precious  minutes  can  never  be  recalled." 

"Eecent  Deaths  Under  Chloroform. — A  death  while 
under  the  influence  of  chloroform,  occurred  in  the  Croydon 
Infirmary  (England)  on  October  18,  1887.  The  patient 
was  a  man  named  James  Portsmouth,  aged  28,  who  came 
under  treatment  on  June  22d,  for  pleurisy  with  effusion.  The 
chest  was  aspirated  on  September  15th,  and  about  four 
pints  of  serum  withdrawn  ;  aspiration  was  repeated  September 
20th,  when  three  pints  of  serum  were  obtained.  On  October 
17th,  the  chf  st,  having  again  filled,  aspiration  was  performed 
for  the  third  time,  and  five  and  a  half  pints  of  pus  were  evacu- 
ated. Following  the  method  of  treatment  which  is  now 
thoroughly  established  as  a  rule  of  surgical  practice.  Dr. 
Francis  W.  Clark,  the  medical  oflBcer  in  charge  of  the  infirm- 
ary, after  consulting  with  Dr.  Strong,  and  Dr.  Matthey,  deter- 
mined to  open  the  chest-wall,  in  order  to  have  free  drainage. 
On  October  18th,  chloroform  was  administered,  and  the  opera- 
tion was  performed  in  the  ordinary  manner.  {British  Medical 
Journal,  Nov.  5,  '87.)  During  the  last  steps  of  the  operation, 
symptoms  of  syncope  suddenly  developed,  and  all  efforts  to 
restore  the  patient  were  unavailing.  An  inquest  was  held,  and 
the  jury  returned  a  verdict,  in  accordance  with  the  medical 
evidence,  which  recited  the  above  facts. 

"Comments  by  the  editor  of  British  Medical  Journal :  We 
understand  that  the  Board  of  Guardians  have  instituted  an  in- 
quiry into  the  circumstances.  This  is  not  likely  to  have  any 
useful  result.  The  operation  was  absolutely  necessary,  and 
every  precaution  was  taken  in  administering  the  anajsthetic,  but 
it  is  impossible,  with  the  greatest  care,  to  avoid  all  danger. 
Deaths  have  occurred  with  both  the  anajsthetics  in  general  use, 
and  under  the  hands  of  the  most  experienced  operators. 

"Remarks  on  the  above  subject  by  I.  Frederick  W.  Silk, 
M.D.,  Anaesthetist  to  the  Great  Northern  Hospital,  and  to  the 
National  Dental  Hospital,  London  : 

">S'ir — Your  issue  of  October  29th,  contains  an  account  of  an- 


EXTENSIVE  EMPLOYMENT  OF  CHLOROrORM.     419 

otlaer  death  under  the  influence  of  chloroform,  and  the  frequent 
repetition  of  these  announcements,  cannot  but  strike  the  most 
superficial  observer,  and  has  led  me  to  address  a  few  remarks 
to  you  upon  the  subject,  while  the  matter  is  still  fresh  in  the 
minds  of  your  readers. 

"Apart  from  the  actual  number  of  deaths,  one  cannot  but  feel 
surprised  at  the  equanimity  with  which  the  profession  at  large, 
and  surgeons  in  particular,  view  these  constantly  recurring  ac- 
cidents, and  at  the  slight  efforts  which  appear  to  be  made  to 
impi'ove  matters,  even  in  directions  where  improvement  is  ob- 
viously possible.  Such  considerations  not  unnaturally  suggest 
two  questions,  namely : 

"  1.  Why  is  it  that  chloroform  is  still  so  extensively  employed 
as  an  anaesthetic  for  general  use?  I  quite  admit  that  in  spe- 
cial cases  it  is  invaluable — even  absolutely  necessary — but,  as 
far  as  I  can  judge,  the  only  claim  for  general  use  it  has  upon 
our  consideration,  is,  that  it  need  not  be  given  in  any  special 
form  of  apparatus,  proficiency  in  the  use  of  which  might  re- 
quire a  longer  or  shorter  course  of  special  training.  Ether  has 
long  been  proved  to  be  infinitely  safer,  and,  judiciously  admin- 
istered, fulfils  all  possible  requirements;  while  properly  com- 
bined with  nitrous  oxide  gas,  the  violent  struggling  may  be 
reduced  to  a  minimum,  the  patient  rendered  insensible  to  the 
unpleasant  odor,  and  the  subsequent  sickness,  etc.,  much  re- 
duced. It  is  true,  that  to  produce  anaesthesia  by  the  combined 
method,  a  certain  amount  of  training  in  the  use  of  more  or  less 
complicated  inhalers,  etc.,  is  necessary;  but  will  any  one  seri- 
ously put  an  argument  forward,  in  favor  of  the  use  of  a  method 
which  has  been  proved  over  and  over  again,  to  be  fraught  with 
danger,  and  risk  to  life?  I  am  aware,  that  I  have  advanced 
none  but  the  most  trite  arguments  in  favor  of  the  combined 
method,  and  against  the  free  use  of  chloroform ;  but,  in  the 
present  apathetic  state  of  opinion  upon  the  subject,  the  most 
veritable  truisms  will,  I  am  sure,  be  as  valuable  as  the  most 
precise  reasoning. 

"2.  When  will  it  be  recognized,  both  in  theory  and  practice, 
that  the  responsibility  which  devolves  upon  the  anaesthetist  is 
quite  as  great,  as,  or  in  some  cases  even  greater  than,  that  of 


420  ARTIFICIAL  ANESTHESIA. 

the  operator ;  and  that  his  training  should  be  proportionately 
careful,  and  systematic?  Considering  that,  but  for  the  discov- 
ery of  ether,  chloroform  or  some  similar  agent,  the  practice  or 
surgery  would  hardly,  in  such  a  comparatively  short  time,  have 
reached  its  present  very  scientific  state,  it  is  curious  to  note 
how  completely  the  subject  of  anajsthesia  has  dropped  into  the 
background  in  general  estimation. 

"  In  making  these  remarks,  I  have  endeavored  most  carefully 
to  refrain  from  alluding  even  remotely  to  individual  cases.  I 
have  simply  seized  the  opportunity,  which  recent  accidents 
aflford,  of  bringing  the  subject  in  its  entirety  before  the  notice 
of  such  as  may  be  interested,  or  able  to  influence  others,  and 
for  whose  benefit,  I  would  sum  up  the  points  I  have  endeavored 
to  make,  namely : 

"  1.  Chloroform,  though  of  great  service  in  special  cases, 
should  not  be  employed  for  general  use. 

"  2.  For  general  purposes,  the  combined  gas  and  other  methods 
will  be  found  to  more  than  fulfill  every  possible  requirement. 

"  3.  That  more  systematic  instruction  should  be  given  on 
the  subject." 

At  how  many  medical  schools  (we  know  of  but  one  in  Phil- 
adelphia— the  Philadelphia  Dental  College)  are  any,  but 
slight  attempts  made,  to  give  instruction  in  a  systematic  man- 
ner, on  a  subject  which  we  venture  to  think  is  not  the  least 
important  in  the  curriculum  ? 

The  following  is  the  death  under  chloroform,  referred  to, 
by  the  writer,  above  cited  : 

"A  death  is  reported  from  Westminster  Hospital,  under  chlo- 
roform {British  Medical  Journal,  Oct.  29,  '87).  A  patient,  a 
young  man  aged  30,  was  about  to  undergo  the  operation  of 
stretching  the  sciatic  nerve,  for  sciatica  of  long  standing. 
Ether  was  given  in  the  first  instance,  under  the  influence  of 
which  he  struggled  violently.  On  being  brought  into  the 
operating  theatre,  chloroform  was  administered  in  order  to 
bring  him  well  under,  but  almost  immediately  he  Wfis  ob- 
served to  turn  pale,  and  both  pulse  and  respiration  ceased." 

"Died  While  Under  Chlorofoem.— Stanley  Carl,  30 
years  of  age,  who  for  some  years  has  been  a  lion-tamer,  and 


DEATH   FEOM   CHLOROFORM.  421 

trainer  in  Forepaugh's  Circus,  died  at  the  Medico-Chirurgical 
Hospital,  wliile  under  the  influence  of  chloroform,  preparatory 
to  undergoing  a  minor  operation  on  a  knuckle  of  his  right 
hand.  Every  effort  known  to  science,  was  made  to  resuscitate 
him,  as  soon  as  it  was  discovered  that  he  was  sinking.  Dr. 
Formad,  the  coroner's  physician,  in  his  post-mortem,  found 
that  Carl  had  been  suffering  from  liver  and  kidney  troubles, 
and  also  from  fatty  degeneration  of  the  heart.  His  death 
under  the  ansesthetic,  is  attributed  to  the  latter  cause.  So  far 
as  known,  he  leaves  no  family."     (Press,  Feb.  7,  1887.) 

"Professor  Pancoast,  was  visibly  affected  as  he  related  to  the 
coroner's  jury,  yesterday,  the  circumstances  attending  the  sad 
death  of  Stanley  Carl,  the  lion-tamer  and  trainer,  aged  30 
years,  of  927  Eace  Street,  at  the  Medico-Chirurgical  Hospital 
on  Wednesday. 

"The  man  had  received  an  injury  to  one  of  his  hands,  during 
a  scuffle  with  a  colored  man  at  the  Dime  Museum,  where  he 
was  employed,  several  weeks  ago,  and  went  to  the  hospital  to 
have  the  wounded  member  operated  upon.  Professor  Pan- 
coast,  said,  that  he  had  taken  a  strong  personal  interest  in  the 
man.  He  was  a  sturdy,  brave,  frank-spoken  fellow.  He  had 
previously  been  under  treatment,  and  had  told  the  witness,  that 
he  had  been  informed  he  must  sacrifice  one  of  the  knuckles  of 
the  right  hand.  A  few  days  ago  he  visited  Professor  Pancoast, 
and  said,  '  Doctor,  I  would  rather  die,  than  lose  my  right 
hand.' 

" '  My  heart  was  touched,'  continued  the  witness,  '  and  I 
offered  to  do  what  I  could  for  him,  without  charge.  I  found 
that  the  hand  was  without  motion,  and,  knowing  what  a  brave 
fellow  he  was,  and  how  he  could  endure  pain,  I  endeavored  to 
break  the  adhesions  of  the  tendons,  so  as  to  restore  motion. 
Strong  as  he  was,  he  could  not  bear  the  pain,  and  I  had  to  de- 
sist, and  resort  to  an  anaesthetic' 

"  The  witness  explained,  that  his  method  of  using  anaesthetics 
was  one,  which  was  endorsed  by  two  distinguished  bodies  of 
medical  experts,  in  Paris.  The  death  of  Carl,  was  the  most 
remarkable  experience  that  the  witness  had  had,  in  a  practice 
extending  over  thirty- four  yaers.     '  My  early  training,' con- 


422  ARTIFICIAL   ANiESTIIESIA. 

tinued  the  professor,  'was  in  the  direction  of  learning  fully, 
the  uses,  effects,  and  application,  of  aniesthctics.  The  death  of 
Carl,  is  a  very  painful  occurrence — doubly  painful  to  me.' 

"Professor  Pancoast  then  described  the  operation.  He  said 
that  every  precaution  had  been  taken  to  insure  the  safety  of 
the  operation.  Carl  was  placed  on  his  back,  and  made  to  ex- 
tend his  hands  upwards,  at  full  length.  Half  a  teaspoonful  of 
chloroform  was  applied  to  a  towel,  and  the  witness  took  hold 
of  the  injured  hand.  The  patient  cried  out  in  agony,  and 
asked  for  more  of  the  anaesthetic.  Not  more  than  two  tea- 
spoonfuls  in  all  were  given  him,  and  then  the  witness  began 
the  operation.  The  hands  remained  extended,  the  legs  moved 
and  there  was  every  evidence  of  vitality.  At  the  conclusion 
of  the  operation,  the  witness  looked  at  the  patient  and  found 
that  his  face  was  livid,  and  there  was  a  great  difBculty  in 
breathing.  Observing  that  there  was  something  wrong,  reme- 
dies for  resuscitation  were  tried.  When  the  legs  were  raised, 
the  face  became  more  congested."  The  symptoms  were  not 
those  of  a  man  dying  from  the  effects  of  chloroform.  In  con- 
clusion, the  professor  said :  '  The  case  is  wonderful,  and  I  have 
never  seen  anything  like  it.' 

"  Dr.  Stubbs,  one  of  the  professors  of  the  college,  testified  that 
in  twenty-four  years'  practice  he  had  never  seen  a  death  like 
that  of  Carl,  from  either  chloroform,  or  ether.  Efforts  to  resus- 
citate the  patient  were  utterly  ineffectual,  even  to  the  tapping 
of  the  jugular,  which  was  done  to  allow  the  discharge  of  blood, 
which  was  surcharged  with  carbonic  acid,  resulting  from  the 
use  of  chloroform.  During  the  operation,  the  patient  showed 
every  indication  of  vitality. 

"  Dr.  Formad,  coroner's  physician,  testified  that  death  was 
due  to  paralysis  of  the  heart,  hastened  by  the  action  of  chlo- 
roform. There  was  evidence  of  latent  heart  disease,  and  a 
chronic  affection  of  the  kidneys.  The  jury  rendered  a  ver- 
dict in  accordance  with  the  facts,  and  exonerated  the  surgeons 
from  all  blame.  To  this.  Professor  Pancoast  remarked :  '  A 
very  just  verdict,  gentlemen,  and  I  thank  you.  No  one  can 
feel  this  more  than  I  do.' " 

The  experiments  of  Dr.  Lauder  Brunton,  on   the  sedative 


CHLOKOFOEM  DEATH  IN  DENTIST's  CHAIR.       423 

effect  of  chloroform  upon  the  heart's  action,  and  the  reflex 
phenomena,  on  irritation  of  the  sensory  filaments  of  the  fifth 
nerve,  show,  that  a  small  dose  of  chloroform  is  a  most  danger- 
ous thing.  Too  much  caution  cannot  be  written  and  taught, 
that  the  heart-power  is  most  seriously  reduced  by  its  action, 
and  that  it  is  incapable  of  supplying  the  brain  properly,  un- 
less the  patient  is  in  a  recumbent  posture. 

"Another  Death  from  Chloroform  in  a  Dentist's 
Chair.— Chicago,  April  28,  1888.  Dr.  W.  E.  Day,  in  whose 
dental  ofl5ce  Mrs.  J.  J.  Shay  died,  while  under  the  influence  of 
chloroform,  yesterday,  was  arraigned  to-day  on  the  charge  of 
manslaughter.  The  coroner's  jury  not  having  returned  a  ver- 
dict, the  case  was  postponed  until  Thursday.  The  doctor  was 
unable  to  procure  security  for  the  $5000  bonds  in  which  he 
was  held,  and  remains  in  jail.  When  Mrs.  Shay  visited  Dr. 
Day's  oflice,  she  was  accompanied  by  her  sister,  Mrs.  Madden, 
of  Pullman.  She  wanted  all  her  teeth  extracted,  and  the  doc- 
tor insisted  that  she  must  take  chloroform.  Mrs.  Shay  ob- 
jected, and  told  the  doctor  that  she  was  subject  to  heart  disease, 
and  that  she  feared  that  the  administering  of  an  anaesthetic 
might  result  fatally.  The  dentist  then  felt  her  pulse,  and  as- 
sured her  that  there  was  no  danger,  as  he  did  not  think  she 
had  heart  disease.  The  patient  was  finally  persuaded  to  follow 
his  advice.  She  took  the  seat  and  the  drug  was  applied. 
When  three  of  her  teeth  had  been  drawn,  she  showed  signs  of 
revival,  and  was  drugged  once  more,  and  three  more  teeth 
were  taken  out,  and  again  there  were  signs  of  returning  con- 
sciousness, 

"  For  the  third  time  the  drug  was  administered,  when  the 
collapse  came.  The  patient  was  removed  from  the  chair  to  a 
lounge,  where  she  died  within  a  few  minutes  in  spite  of  the 
efforts  of  a  doctor,  who  had  been  hastily  called  in.  This  is  the 
story,  as  told  by  Mrs.  Madden.  Dr.  Day,  denies  that  he  ad- 
ministered chloroform  more  than  once,  and  insists  that  the 
patient  died  from  a  nervous  shock.  Dr.  Day  has  practiced 
dental  surgery  in  Chicago,  since  1876.  OflBcers  of  the  State 
Dental  Association,  say,  that  be  holds  no  diploma  from  any 
worthy  institution,  and  that  he  is  ostracized  from  associations, 


424  ARTIFICIAL   AN.i:STHESIA. 

because  he  violates  professional  ethics,  by  promiscuous  advertis- 
ing. It  is  claimed  by  them,  that  no  dentist  has  the  right  to 
administer  chloroform,  without  skillful  professional  aid  from 
some  physician.  The  drug  is  very  little  in  use,  it  is  said, 
among  reputable  dentists." 

"  Death  Under  Chloroform. — On  Wednesday,  Dr.  Hard- 
wicke  held  an  inquiry  on  the  body  of  Harry  Knowlton,  aged 
seven  years,  son  of  a  smith,  living  at  1  Reraerton  Street, 
Barnsbury,  who  expired  in  the  University  College  Hospital, 
while  under  chloroform,  administered  for  the  purpose  of  an 
operation.  The  evidence  showed,  that  for  the  last  two  years, 
deceased  had  been  under  treatment  in  four  hospitals  for  con- 
traction of  the  sinews  of  the  legs  and  arms  ;  and,  at  last,  he  was 
taken  to  the  University  College  Hospital.  On  Thursday,  he 
was  placed  under  bichloride  of  methylene,  and  was  operated 
on  by  Mr.  Marshall,  the  senior  surgeon,  who  ordered  that  next 
day  he  should  be  again  placed  under  the  vapor,  and  splints 
put  on  to  his  limbs.  He  was  removed  into  the  ward,  and  the 
following  day,  Mr.  Sayer,  one  of  the  resident  medical  officers, 
administered  chloroform,  with  a  view  to  carrying  out  Mr.  Mar- 
shall's instructions.  At  first  deceased  became  excited,  but 
getting  quieter,  the  house-surgeon  began  the  operation,  when 
it  was  found  that  he  was  not  sufficiently  under  the  inlluence 
of  the  chloroform,  and  more  was  about  to  be  administered, 
when  it  was  found  that  re^^piration  had  ceased.  Artificial 
respiration  was  resorted  to,  but  without  success.  Jury  returned 
a  verdict,  of  death  through  misadventure."  {Briilsh  Medical 
Journal.) 

"  Died  in  the  Dentist's  Chair. — Cincinnati,  Ohio,  Feb.  22, 
1889.  A  despatch  from  Norwalk,  Ohio,  says  that  Miss  Minnie 
Marsaeles,  a  young  lady  of  that  city,  died  in  the  dentist's  chair 
yesterday.  She  had  taken  chloroform  preparatory  to  having 
teeth  drawn,  and  it  caused  her  heart  to  cease  beating.  It  is 
thought  she  was  affected  with  heart  disease." 

It  is  stated  in  the  editorial  notes  [Am.  Med.  Ass.  Journal, 
March  2d,)  that  she  "  partly  recovered  from  the  drug  "  when  she 
started  to  rise  from  the  chair,  but  suddenly  sank  back  and 
died.     From  the  meagre  information  conveyed  in  the  press  dia- 


CHLOEOFORM  GIVEN  IMPEOPERLY.       425 

patches,  one  cannot  know  whether  the  chloroform  was  adminis- 
tered by  the  dentist  himself,  whether  the  administrator  was  a 
physician,  or  a  person  sufficiently  skilled  to  administer  chloro- 
form ;  but  one  can  scarcely  conceive  of  a  skillful  ansesthetizer, 
giving  chloroform  to  any  one  in  a  dentist's  chair  under  any 
circumstances.  A  person  that  would  give  chloroform  to  a 
patient  in  a  chair  would  probably  not  take  the  other  necessary 
precautions  when  about  to  give  chloroform,  such  as  removing 
all  sources  of  constriction  of  the  body. 

Is  it  not  time  that  dentists,  and  physicians,  also,  learn  that 
chloroform  is  a  very  dangerous  drug  when  given  improperly  ? 
With  the  other  means  of  ansesthesia  that  we  have,  is  the  use 
of  chloroform  for  tooth  extracting  justifiable?  The  fact  that 
teeth  have  been  extracted  under  chloroform,  and  without  in- 
jury to  the  patient,  does  not  justify  its  use  for  this  purpose. 
The  surgeon  that  would  seat  a  patient  fully  clothed  in  a  chair, 
and  give  chloroform  to  amputate  a  finger,  or  even  open  an  ab- 
scess, would  be  guilty  of  negligence,  if  any,  short  of  criminal- 
ity. We  are  too  much  inclined  to  excuse  blunders,  hoping 
that  the  blunderers  have  been  taught  a  salutary  lesson,  which, 
however,  is  of  no  benefit  to  the  person  that  has  come  to  an 
untimely  death.  There  should  be  more  care  in  dealing  with 
the  ills,  to  which  the  flesh  is  heir,  that  the  patient  survive  the 
treatment.  "It  is  a  well-recognized  rule,  that  a  patient  should 
never  immediately  assume  the  upright  posture,  especially  after 
the  use  of  chloroform,  whose  chief  depressing  influence  is  upon 
the  heart,  for  it  has  been  found  that  they  at  once  faint,  and  by 
placing  their  head  low,  the  blood  returns  to  the  brain,  and 
heart,  and  the  patient  is  safe.  This  well-known  method  of 
Nelaton  has  had  to  be  employed  in  several  instances  in  the 
same  case,  and  thus  saved  the  life  of  the  patient.  The  heart 
of  every  patient,  should  be  examined  before  a  systemic  anaes- 
thetic is  employed,  and  to  a  patient  with  a  fatty  heart,  chloro- 
form should  never  be  given." 

It  was  published  in  the  Louisville  Medical  News,  May  26, 
1883,  that  during  the  last  year,  two  deaths  from  chloroform  had 
occurred  in  the  practice  of  two  prominent  Southern  surgeons. 
Dr.  Kinlock,   of  Charleston,   and'  Dr.  Hunter  McGuire,   of 


426  ARTIFICIAL   ANAESTHESIA. 

Richmond,  which  have,  "doubtless,  detracted  from  the  favor  in 
which  chloroform  is  held  in  the  South,  and  advanced  the 
popularity  of  ether  as  a  safer  agent,  though  not  so  prompt  in 
its  effects.  In  the  North,  and  East,  ether  has  long  held  un- 
disputed sway,  and,  with  a  few  exceptions,  has  enjoyed  a  higher 
degree  of  confidence. 

"  It  is  now  beginning  to  be  observed  by  the  profession  gener- 
ally, that  there  is  something  of  very  material  importance  in  the 
manner  in  which  aniesthetics  are  administered — that  there  is 
an  anaesthetic  art,  deserving  careful  study,  and  application  in 
practice.  It  is  not  an  uncommon  observation  to  see  the  ad- 
ministration of  the  anajithetic,  intrusted  without  discrimination 
to  an  assistant,  who  holds  the  paper  cone  carelessly  over  the 
patient's  face,  and  watches,  in  the  meantime,  the  various  steps 
of  the  operation.  Can  it  be  wondered,  that,  in  a  process  in- 
volving such  essential  physiological  functions,  dangerous  and 
alarming  symptoms  arise  under  these  circumstances?  Un- 
questionably, the  administration  of  the  anaesthetic  should 
receive  the  undivided  attention,  during  an  operation,  of  one 
who  has  by  study,  and  training,  acquired  a  knowledge  of  the 
proper  method  of  administering  the  agent,  and  who,  in  circum- 
stances of  danger,  will  be  prepared  to  act  promptly  and 
intelligently  in  his  efforts  at  restoration." 

Death  from  Chloroform  Narcosis. — Failure  of  Nela- 
ton's  Method,  and  of  the  Amyl  Nitrite  Treatment. — 
The  following,  is  a  death  from  chloroform  in  the  practice 
of  Professor  McGuire.  Dr.  Hugh  M.  Taylor,  of  Richmond, 
Virginia,  reports  the  following  case  in  the  Virginia  Medical 
Monthly,  of  May,  1878  : 

"  Professor  McGuire,  has  requested  me  to  report  the  following 
death  from  chloroform,  which  occurred  a  few  days  ago  in  his 
practice.  As  far  as  I  can  learn,  it  is  the  second  death  from 
this  agent  which  has  occurred  in  our  city,  and  is  one  of  the 
very  few,  recorded  by  our  Southern  surgeons : 

"  The  patient  was  a  gentleman  from  North  Carolina,  set.  41 
years.  Twelve  or  fourteen  months  ago  he  received  a  violent 
blow  upon  his  perineum,  by  being  thrown  upon  the  pommel  of 
a  saddle.     His  urethra  was  ruptured;    this  was  followed  by 


OPERATION  UNDER  CHLOROFORM.  427 

urinary  infiltration,  abscesses,  resulting  in  the  loss  of  the  entire 
penis,  and  part  of  the  scrotum.  Since  that  time,  he  has  been  a 
very  great  sufferer,  and  has  become  entirely  dependent  upon 
anodynes,  frequently  taking  as  much  as  two  grains  of  the 
sulphate  of  morphia  a  day.  During  the  last  six  months  of 
his  sickness,  he  has  spent  most  of  his  time  in  bed,  or  in  the 
recumbent  position. 

"On  the  day  of  operation,  April  20th,  1878,  (Doctors  Cun- 
ningham, Eoss,  Leach,  Maclin,  and  Carroll  co-operating), 
Squibb's  purified  chloroform  was  administered,  for  the  purpose 
of  making  a  direct  outlet  for  the  urine  by  external  perineal 
urethrotomy.  The  administration  of  the  anaesthetic  was  begun 
while  the  patient  was  in  his  bed.  He  was  then  put  upon  a 
table  in  the  lithotomy  position,  and  the  table  was  drawn  near 
an  open  window,  occupying  a  position  directly  between  the 
open  window,  and  an  open  door.  I  noticed,  when  giving  him 
chloroform  in  his  bed,  that  he  was  not  easily  brought  under  its 
influence.  Some  delay  occurred  in  the  first  part  of  the  oper- 
ation in  consequence  of  the  extensive  undermining  of  the 
tissues,  and  burrowing  of  the  urine,  and  pus,  leaving  a  great 
number  of  false  passages,  and  rendering  it  tedious  to  get  a 
guide  of  any  sort  into  the  bladder.  Daring  this  stage  of  the 
operation,  he  was  not  kept  fully  under  the  chloroform.  After 
some  effort,  the  continuation  of  the  urethra  was  found,  and  an 
instrument  passed  into  the  bladder.  The  administrator  then 
carried  the  anaesthesia  far  enough,  to  allow  the  operation  to  be 
finished.  He  had  done  this,  and  had  taken  the  chloroform 
away  for  a  few  seconds,  when  we  were  all  startled  by  one  or 
two  stertorous  respirations,  and  then  followed  an  entire  ces- 
sation of  respiratory  effort. 

"  In  less  time  than  I  can  tell,  his  tongue  was  drawn  for- 
ward with  a  tenaculum ;  his  feet  were  raised,  and  his  head  was 
lowered ;  water  was  dashed  in  his  face ;  his  cheeks  smacked  ; 
nitrite  of  amyl  held  to  his  nose.  As  none  of  these  aroused, 
him,  he  was  quickly  placed  on  the  table  and  artificial  respi- 
ration resorted  to.  Dr.  Ross,  and  I,  raised  and  depressed  his 
arms,  while  Doctors  McGuire,  and  Cunningham,  compressed  his 
thorax.     Let  me  here  remark,  that  I  am  sure  in  this  case  the 


428  ARTIFICIAL   ANAESTHESIA. 

death  was  not  from  asphyxia,  or  the  impregnation  of  his  blood, 
with  carbonic  acid.  The  efforts  at  artificial  respiration  were 
eminently  successful.  As  the  arms  were  raised,  the  air  rushed 
into  the  lungs,  producing  a  stertor  as  natural  as  life — and  then 
when  the  thorax  was  compressed,  the  blowing  sound  of  exit  was 
plainly  heard.  Indeed,  these  artificial  inspirations  and  expira- 
tion were  so  strikingly  normal,  as  to  deceive  me  for  some  time  into 
believing  them  vital.  During  this  time,  whiskey  was  injected 
into  his  rectum,  amyl  occasionally  held  to  his  nose,  and  the 
foot  of  the  table  elevated.  Only  once,  during  our  prolonged 
efforts  to  resuscitate  him,  was  there  the  least  token  of  returning 
animation,  and  that  was  when  the  first  dash  of  cold  water 
struck  his  face.  Then  he  gasped  feebly — but  once.  His  fea- 
tures from  the  first  were  blanched,  and  bloodless  ;  he  carried  to 
his  grave  the  finger  marks  produced  by  slapping  him;  his 
pupils  were  both  widely  dilated  ;  his  lips  blue.  He  had  been 
under  the  influence  of  chloroform  for  about  three-quarters  of 
an  hour — at  no  time  very  profoundly.  During  this  time,  he 
took  about  §j  of  Squibb's  purified  chloroform.  The  large 
quantity  of  anodynes  which  he  had  accustomed  himself  to, 
and  the  extreme  sensitiveness  of  the  parts  manipulated,  rend- 
ered it  difiicult  to  ancesthetize  him.  He  had  taken  chloroform 
twice,  before  he  came  to  the  city,  and  this  latter  trouble,  viz., 
inability  to  completely  affect  him,  was  noticed  upon  both 
occasions. 

"  In  reviewing  the  case,  the  doctor  concludes,  that  death  was 
brought  about,  through  syncope;  that  amyl,  had  no  effect  in 
replenishing  the  antemic  blood  vessels  of  the  brain;  and  that 
at  least  one  case  has  happened,  when  its  antidotal  virtues  were 
not  at  all  noticeable;  that  the  result  was  of  sudden  occurrence, 
and  of  speedy  termination  ;  that  his  pulse  was  good  a  very  few 
seconds  before,  and  that  the  artificial  respiration  would  have 
oxygenated  any  quantity  of  carbonized  blood,  with  which  his 
lungs  might  have  been  surcharged  ;  that  the  administrator  was 
in  no  manner  to  blame,  as  he  fulfilled  his  part  with  the  utmost 
care  and  skill.  The  verdict  of  all  present  was  'that  death  was 
caused  by  chloroform ;  but  that  the  same  was  carefully,  and 
judiciously  administered,' " 


EMPLOYMENT  OE   NITEITE   OF   AMYL.  429 

Being  desirous  of  knowing  some  obscure  points,  in  regard  to 
the  way  in  which  the  nitrite  had  been  used,  we  wrote  to  Doctor 
Taylor,  addressing  the  following  questions  : — Did  the  nitrite  of 
amyl  produce  a  flushing  of  the  face,  action  of  the  heart,  and 
difiicult  breathing  when  you  employed  it  yourself?  Did  you 
use  a  tube  to  force  it  up  the  nostrils  when  the  breathing  had 
ceased  ?  How  many  drops  were  employed  ?  Was  it  in  capsules 
or  dropped  from  a  bottle? 

The  doctor  kindly  replied,  as  follows  : 

Richmond,  May  31st,  1878. 
Doctor  Turnbull, 

Dear  Sir: — Your  letter,  dated  May  20th,  found  me  out  of  the  city 
for  a  few  days.  I  am  very  glad  to  answer  your  inquiries.  You  say 
that  "Professor  N^laton's  method  will  sometimes  fail,  especially 
when  morphia  has  been  used  with  the  chloroform."  No  morphia 
was  given  at  the  time,  with  the  chloroform.  It  was  during  his  sick- 
ness that  large  quantities  had  "been  administered.  In  regard  to  the 
amyl  used,  it  was  made  by  Squibb,  and  was,  I  think,  pure.  I  am 
sorry  I  cannot  find  a  sample  of  it  to  send  you  for  examination.  It 
was  dropped  from  a  bottle  upon  a  handkerchief.  The  number  of 
drops  were  not  ascertained.  No  tube  was  introduced  into  the  nose. 
Very  respectfully,  etc. , 

Hugh  M.  Taylor.* 

"  Death  from  Chloroform  in  which  the  Nitrite  of 
Amyl  was  Employed  without  Success. — Another  death 
in  the  hands  of  a  Southern  surgeon :  Death  from  chloro- 
form April  29th,  1879,  by  W.  P.  Mills,  M.D.,t  of  Browns- 
ville, Mobile.  I  was  requested  to  operate  on  a  boy  aged  16 
years,  for  congenital  phimosis.  He  was  chloroformed  by 
Dr.  A.  J.  Parsons,  who  has  often  administered  chloroform  by 
inhalation,  and,  by  the  way,  he  is  very  cautious  in  the  adminis- 

*We  do  not  think  the  doctor  was  justified  in  the  use  of  so  powerful  an  anaes- 
thetic, to  risk  his  patient's  life  in  so  trifling  an  operation.  Evidently  the  nitrite  of 
amyl  was  not  employed  until  the  patient  had  become  unable  to  inhale  it.  The  con- 
clusions are  not  the  most  recent,  as  a  careful  reading  of  our  table  of  deaths  from  it, 
will  show.     It  gives  but  little  warning  before  it  kills  the  patient. 

t  St.  Louis  Medical  and  Surgical  Journal,  June,  1878,  p.  492. 


430  ARTIFICIAL  ANiESTHESIA, 

tration  of  this  potent  drug.  Notwithstanding  the  great  pru- 
dence, caution,  and  the  general  manner  in  which  it  was 
administered,  just  as  the  operation  was  completed,  and  without 
any  indication  of  danger  whatever,  instantaneously — almost  as 
quick  as  the  explosion  of  gunpowder — respiration  ceased,  and 
a  livid  color  overspread  his  face,  and  in  spite  of  all  the  usual 
restoratives,  he  was  soon  dead ;  in  fact,  it  seemed  aa  if  he  was 
struck  dead  in  an  instant.  Immediately,  upon  the  supervention 
of  these  alarming  symptoms,  his  head  was  lowered,  cold  water 
thrown  into  his  face,  and  artificial  respiration  induced.  Under 
the  influence  of  this  treatment  some  improvement  was  mani- 
fested, and  for  a  few  seconds  it  seemed  that  the  danger  Avas 
over,  but  suddenly  all  the  alarming  symptoms  before  described 
were  again  exhibited,  and  death  was  the  inevitable  result.  Not 
more  than  three  drachms  of  chloroform  were  used,  and  of  this 
not  more  than  one  and  a  half  or  two  drachms  were  actually 
inhaled,  and  the  patient  was  not  deeply  under  its  influence  at 
any  time  during  the  operation,  which,  as  a  matter  of  course, 
was  very  brief.  Nitrite  of  amyl,  electricity,  and  hypodermic 
injections  of  whiskey  were  all  brought  into  requisition,  but,  as 
the  sequel  proved,  were  of  no  avail.  The  most  noteworthy 
feature  of  the  case  was  the  very  sudden  supervention  of  the 
alarming  symptoms,  for,  according  to  my  information  in  regard 
to  chloroform  poisoning,  there  is  generally  some  warning  given 
of  its  deleterious  influence." 

"  Death  fkom  Chlorofokm. — On  the  unfortunate  death  of 
the  Lady  Flora  Wilmot,  whilst  under  the  influence  of  chloro- 
form for  the  extraction  of  a  tooth,  Mr.  J.  Farrant  Fry,  the 
medical  practitioner  who  administered  the  anasthetic,  com- 
municates to  The  Lancet  the  following  observations  : 

**  I  beg  to  forward  you  particulars  of  the  recent  death  here 
from  chloroform.  The  Lady  Flora  Wilmot,  aged  twenty-five 
years,  had  been  under  my  care  for  various  minor  ailments 
during  the  last  eighteen  months.  With  the  exception  of  a 
gouty  tendency,  her  constitution  was,  I  believe,  sound.  On 
Wednesday,  February  24th,  I  was  asked  to  meet  her  at  Mr. 
Scott's  residence,  at  Swansea,  (her  dentist)  for  the  purpose  of 
administering  an  anaesthetic  for  the  extraction  of  the  right 


DANGEE   OF   UPEIGHT   POSITION.  431 

molar  tooth.  Nitrous  oxide  gas  not  being  available,  I  gave 
chloroform,  in  preference  to  bichloride  of  methylene  or  ether 
(both  of  which  I  had  by  me),  because  for  the  purpose  I  con- 
sidered it  the  best  ansesthetic,  and  also  because  her  ladyship, 
having  taken  it  two  or  three  times  before,  expressed  a  prefer- 
ence for  it.  Everything  about  the  chest  being  perfectly  loose, 
and  the  patient  sitting  in  the  dentist's  chair,  less  than  a 
drachm  was  sprinkled  on  lint  in  an  open  inhaler,  which  the 
gag  kept  from  closely  fitting  round  the  mouth  and  nose.  A 
similar  quantity  of  chloroform  was  added  a  second  and  third 
time  before  perfect  anaesthesia  occurred.  The  tooth  was  then 
removed,  and  recovery  followed  without  a  bad  symptom.  The 
patient  had  taken  it  capitally,  and  in  all  two  drachms  had 
been  given.  Five  days  afterwards  (March  1st,)  I  again  admin- 
istered chloroform  for  Mr.  Scott,  (this  time  at  the  patient's 
residence),  to  remove  the  adjoining  bicuspid  tooth.  The  pa- 
tient was  seated  in  a  low,  deep-backed,  well-pillowed  easy 
chair,  and  was  therefore  more  reclining  than  on  the  former 
occasion.  The  result  of  the  chloroform  before  having  been  so 
satisfactory,  I  again  administered  it  in  the  same  way,  and,  as 
before,  two  drachms  were  given  in  all,  with  a  similarly  good 
result.  The  inhaler  having  been  removed,  Mr.  Scott  took  out 
the  tooth,  cleaned  his  forceps,  and  stood  by  the  patient's  side. 
I  remarked:  'I  hate  giving  chloroform  for  you  dentists,  be- 
cause you  will  have  your  patients  sitting  up.'  This  led  to  a 
reply  from  Mr.  Scott,  who  then  poured  out  a  tumblerful  of 
water,  and  asked  the  patient  to  rinse  her  mouth,  as  the  gums 
were  bleeding.  No  water  was  taken,  and  I  observed  she  was 
not  sufficiently  conscious  yet,  and  we  still  stood  by  the  patient. 
I  had  during  this  time  one  finger  on  the  temporal  artery, 
whilst  with  the  other  hand  I  was  raising  the  eyelid  and  watch- 
ing the  pupil,  which,  having  been  dilated  during  unconscious- 
ness, had  become  normal,  and  the  conjunctiva  sensitive.  Sud- 
denly the  pupil  became  again  wddely  dilated;  I  could  no 
longer  feel  the  pulse,  and  the  face  became  blanched.  The 
chair  was  immediately  turned  back,  the  head  lowered  to  the 
ground,  and  the  body  and  limbs  raised.  Nitrite  of  amyl, 
sprinkled  on  a  handkerchief,  was  applied  to  the  nose,  and. 


432  ARTIFICIAL   ANAESTHESIA. 

although  the  heart  could  not  be  felt  beating,  the  breathing 
still  continued  for,  I  should  say,  at  least  two  minutes.  Arti- 
ficial respiration,  drawing  out  the  tongue,  and  lifting  the  jaw 
forward,  were  of  no  avail;  not  the  slightest  sign  of  recovery 
followed.  A  po8^-7wor<e??i  examination  was  refused."  {London 
Dental  Record,  April,  1887.) 

Perils  of  Cliloroforin  Admini.stratiou  in  Dental 
Operations. 

Dr.  Brunton  states,  that  if  a  patient  were  not  thoroughly 
under  the  influence  of  chloroform,  any  irritation  of  the  fifth 
nerve  would  produce  slowing  of  the  heart's  action,  and  finally 
stoppage  through  the  pneumogastric  nerve.  He  clearly  .showed 
this  by  an  experiment  on  a  rabbit.  This  may  account  for  the 
deaths  in  the  dental  chair  from  operations  on  the  teeth.  Chlo- 
roform is  the  most  powerful  of  the  ansesthetics ;  too  much  cau- 
tion cannot  be  written  and  taught,  that  the  heart  power  is 
most  seriously  reduced  by  its  action,  and  that  it  is  incapable 
of  supplying  the  brain  jjroperly  unless  the  patient  is  in  the 
recumbent  posture. 

The  researches  of  Richardson,  Rabeteau,  and  others,  have 
shown  that  the  physiological  action  increases  in  intensity  and 
danger,  as  the  number  of  carbon  atoms  increase,  so  that  while 
wood-spirit  (methyl  alcohol),  with  but  a  single  atom  of  car- 
bon, is  transient  and  slight  in  its  effects,  those  of  fusel  oil 
(pentyl  alcohol),  which  has  five  atoms  of  carbon,  are  prolonged 
and  severe. 

The  number  of  deaths  from  chloroform  which  have  occurred 
up  to  date,  will  be  seen  in  tables.  It  will  be  seen  by  a  glance 
how  and  \yhy  deaths  from  chloroform  have  occurred,  and  how 
unsatisfactorily,  in  most  of  the  cases,  the  facts  connected  with 
the  circumstances  have  been  reported. 

Comments  upon  the  Deaths  from  Chloroform.* 

Date  when  Death  occurred  from  Chloroform. — The 
number  of  deaths  in  the  cold  months  were  forty-seven,  and 

♦Abstract  of  table  in  author's  "  Anresthetic  Manual,"  second  edition. 


CHLOROFORM   IN   TRIFLING   AILMENTS.  433 

against  this  we  have  forty-seven  deaths  during  April,  May, 
June,  July  and  August,  showing  but  little  difference  in  regard 
to  temperature. 

Sex. — We  find  there  are  seventy  deaths  in  males,  and  twenty- 
nine  in  females.     Our  results  agree  with  those  of  Sansom. 

Age. — Number  of  cases  over  twenty-one,  fifty -six;  under  it, 
nine,  the  youngest  of  which  was  three  (No.  157);  then  follows 
one  at  six,  eight,  eleven,  twelve,  fourteen,  fifteen,  sixteen  and 
eighteen  years. 

Chabacter,  of  the  Operation"  for  which  the  Chloro- 
form WAS  Administered. — In  many  instances  the  chloro- 
form was  employed  for  trifling  ailments,  which  could  have 
been  relieved  by  less  hazardous  means,  or  in  surgical  opera- 
tions of  minor  importance,  as  follows:  facial  neuralgia,  asthma, 
headache,  toothache,  sleeplessness,  uterine  trouble,  etc.  Of 
the  operations,  there  were  fourteen  cases  of  extraction  of 
teeth;  then  follows  introduction  of  catheter,  extraction  of 
thorn,  amputations  of  fingers  and  toes,  hydrocele,  removal  of 
dead  bone,  dressing  of  fractures,  tumors  of  small  size,  fissure 
of  anus,  cataract,  iridectomy  and  strabismus;  many  of  which 
could  have  been  performed  without  an  anaesthetic,  or,  if  this 
was  insisted  upon,  sulphuric  ether,  or  nitrous  oxide  could  have 
been  employed. 

The  Time  at  which  the  Patient  Died.— In  twenty-four 
instances  before  the  operation,  sixty-one  during,  and  only  ten 
after  the  operation. 

The  Quantity  of  Chloroform  Employed. — The  small- 
est quantity  employed  was  a  few  drops  in  case  No.  142 :  then 
in  case  No.  21,  fifteen  to  twenty  drops;  id  case  No.  166,  forty 
drops ;  case  No.  28,  six  minims,  and  in  eight  cases  one  drachm 
only  was  employed ;  in  twelve  cases,  two  drachms;  from  half 
an  ounce  to  one  ounce  in  most  of  the  other  cases,  with  one 
exception,  in  which  it  was  stated  a  large  amount  in  case  No. 
20  was  employed. 

Form  of  Apparatus. — In  nine  cases  a  towel  or  napkin 
was  used;  in  two,  upon  lint  and  sponge;  one  in  the  sitting 
posture;  in   one,  large  amount  carelessly  administered;  one 
lying  on  abdomen. 
.      19 


434  ARTIFICIAL   ANAESTHESIA. 

Condition  or  Patient. — The  first  most  prominent  con- 
dition of  the  patients  was  the  result  of  habitual  employment  of 
chloroform  (three),  either  to  induce  sleep,  relieve  pain  or  iu 
most  instances  as  an  intoxicant,  at  first  in  moderate  quantity, 
and  then  increasing  it,  foigetting  its  fatal  nature.  The  second 
condition  was  its  fatal  ell'ects  upon  pertons  of  an  intemperate 
habit  (three),  anaamic  (two),  or  disease  of  heart,  or  broken 
down  in  general  health.  On  the  other  hand,  however,  many 
are  cut  down  in  a  perfectly  healthy  condition,  after  the  heart 
has  been  examined  and  considered  all  right  (five). 

Symptoms. — The  most  prominent  symptoms  of  chloroform 
poisoning  will  be  found  to  be  the  fainting  of  the  patient,  fail- 
ure of  the  pulse,  heart's  action  and  ceasing  of  the  respiration, 
stertorous  breathing,  face  livid,  convulsive  movements  and 
dilatation  of  the  pupil. 

The  Cause  of  Death. — Out  of  twenty-seven  cases,  the 
majority  of  deaths  is  stated  to  be  from  collapse  (in  fourteen 
cases),  from  shock  (two),  syncope  (one),  asphyxia  (three),  from 
disease  or  paralysis  of  the  heart  (five),  chloroform  poisoning 
(two). 

PosT-MOKTEM  APPEARANCES.  —  Heart  affections  seem  to 
have  been  the  chief  causes  for  death  reported.  Fatty  degen- 
eration of  the  heart  was  found  in  seventeen  cases;  other  car- 
diac lesions,  nine  cases.  An  examination  of  our  table  will 
prove  the  sad,  but  positive  fact,  that  a  large  number  of  patients 
who  die  from  chloroform  were  healthy  prior  to  taking  the 
fatal  dose  to  relieve  them  of  some  trifling  ailment,  or  for  a 
minor  surgical  operation.  (The  results  confirm  the  experi- 
ments of  Schiff,  who'  stated,  that  in  more  than  five  thousand 
cases  chloroform  paralyzes  the  heart  and  blood-vessels  at 
once  without  previously  paralyzing  the  respiration.)  Thirty 
cases  were  either  healthy,  or  post-mortem  results  were  nega- 
tive; in  one  case  the  patient  had  been  carefully  examined,  and 
no  disease  of  heart  or  lungs  was  found  to  exist;  one  had  in- 
haled chloroform  the  day  before.  In  two  cases,  from  vomit- 
ing, followed  by  deep  inspiration,  the  food  was  found  drawn 
into  the  trachea;  in  one,  tracheotomy  of  no  avail;  in  the  other 
case,  patient  died  alone  (self-administered).    In  many  of  the 


EATIO   OF   DEATHS   FKOM   ANESTHETICS, 


435 


cases  the  post-mortem  conditions  are  given  in  detail,  as  though 
they  were  pathological  changes. 

Chlorofoem  Gives    but    Little    Warking! — The   ra- 
pidity with  which  patients  die  from  it,  is  as  follows : 


1  patient,  instantly,  struggling  stage 

1  "  suddenly 

1  '«  

1  "  

4  "  

1  " 

4  " 

2  "  

2  "  


died  in  1  second. 

1^  minutes. 

2 

3 

5 

6 
10 
15 
a  few 


"  Let  us,"  observes  Professor  Eeichert,  of  the  University  of 
Pennsylvania,  "but  glance  at  the  chloroform  death-list,  and,  as 
horrible  and  incredible  as  it  may  seem,  there  have  been  re- 
ported an  average  of  about  a  death  for  every  month  since  the  time 
of  its  introduction.  With  this  array  of  fully  authenticated 
cases  before  us,  what,  indeed,  must  be  the  actual  number? — 
for  it  must  be  conceded  that  probably  double,  triple,  or  quad- 
ruple as  many  more  were  not  reported,  and  will  never  come  to 
light.  Even  Kappeler  alone  says,  that  he  knows  of  four  cases 
never  reported,  and  personally,  I  know  of  two.  However,  it 
needs  no  words  of  mine  to  remind  the  profession  of  the  dangers 
of  chloroform." 

Table  of  Ratio  of  Deaths  from  Anaesthetics. 

Chloroform  (Lyman) 1  in  5860 

Chloroform  (Richardson) lin  2500  to  3000  * 

Ether  (Andrews) 1  in  23,204 

Ether  (Lyman) 1  in  16,542  f 


*  The  mortality  in  chloroform  is  about  one  in  three  thousand,  and  it  should  not  be 
emploj'ed  except  under  special  circumstances. 

f  In  ether  one  in  about  sixteen  hundred,  and  it  is  the  safest  ansesthetic  in  pro- 
longed operations,  and,  as  a  rule  gives  warning  of  death,  yet  in  a  few  cases  has 
caused  sudden  death. 


436  ARTIFICIAL   ANiESTHESIA. 

Nitrous  oxide  (Rottensten) 1  in  100,000* 

Mixture3  of  chloroform  and  etlier 1  in  6,558  f 

Hydrobromic  ether 1  in  12,500  J 

Bichloride  of  methylene  (pure) 1  in  10,000 

Methylene  mixture 1  in  5,000 

Amylene • 1  in  2380 

Table  of  Deaths  from  the  Various  Ansesthetics. 

Chloroform  (Turnbull,    1888-9) 375 

Chloroform  (Lyman,  1881) 242 

Ether  (Lyman) 27 

Ether  (Turnbull,  1880) 52 

Nitrous  oxide 3 

Amylin  (Buxton) 2 

Hydrobromic  ether 2 

Hydrobromic  ether  mixture 1 

Mixture  of  ether  and  chloroform 4 

Mixture  of  ether,  alcohol  and  chloroform 2 

Bichloride  of  methylene 6 

Methylene  mixture .      2 

Amylene •    • 2 

In  a  recent  paper  by  Dr. Gaspar  Griswold  on  "Electricity  as 
a  Stimulant  in  Cardiac  and  Respiratory  Failure,"^  he  clearly 
proves  that  "  The  pneuraogastric  nerve  retains  its  excitability 
in  chloroform  poisoning,  and  it  is,  therefore,  extremely  dan- 
gerous to  apply  electricity  to  the  neck  in  this  condition.  In 
asphyxiation  by  ether,  he  found  that  the  heart  could  stand 
stimulation  of  the  pneumogastric  as  well  as  in  health,  and  he 
concluded,  therefore,  that  it  was  safe  to  stimulate  the  phrenic 
nerve  to  a  certain  extent  in  this  condition."  (See  more  recent 
conclusions  from  experiments  by  Drs.  Hare  and  Martin,  p.  396.) 

*  Nitrous  Oxide. — This  is  the  safest  anrostlietic  in  sliort  operations,  but,  like  all 
aiiajstlietics,  death  may  occur  from  syucope.  It  may  also  be  combined  with  ether  for 
prolonged  anaesthesia  in  dentistry. 

■j-  Mixtures  containing  chloroform  and  ether  hayo  the  objection  of  the  different 
■volatility  of  the  two  agents,  and  toward  the  last  the  patient  is  apt  to  receive  only 
chloroform. 

X  Hydrobromic  ether  is  suitable  for  short  operations,  and  has  the  tendency  to  pro- 
duce rigidity  of  the  muscles,  acting  like  nitrous  oxide,  but  not  so  safe, 

i  Medical  Keics,  February  28,  1885,  p.  241. 


CASES   IN   WHICH   CHLOROFOEM   IS   SAFE.        437 


In  wliat  Class  of  Cases  can  Chloroform  he  Em- 
ployed with  safety? 

Chloroform,  in  certain  conditions,  is  a  direct  cardiac  de- 
pressant, while,  as  expressed  by  Dr.  Fordyce  Barker,  "In 
obstetrics,  he  had  found  that  chloroform  had  a  very  different 
effect  from  that  which  it  had  when  given  as  an  anaesthetic  in 
surgical  practice.  The  reason  that  he  assigned  for  this  was, 
that  in  surgical  practice  the  anaesthetic  was  given  to  anticipate 
suffering,  while  in  the  case  of  the  parturient  woman,  it  was 
used  for  the  relief  of  pain  already  existing.  Under  the  latter 
circumstances  he  believed  the  system  would  tolerate  the  de- 
pressing influence  of  the  drug,  which  it  might  not  in  ordinary 
conditions. 

"  It  had  long  been  an  accepted  point  in  the  opinion  of  the 
profession  that  it  was  unsafe  to  administer  an  anaesthetic 
when  there  was  organic  disease  of  the  heart,  but  it  was  at 
least  twenty-five  years  since  he  had  ceased  to  believe  that  the 
existence  of  such  was  a  contraindication  against  the  use  of 
chloroform  in  pregnant  women.  On  the  contrary,  the  pres- 
ence of  cardiac  trouble  was,  to  him,  an  indication  which  in- 
duced him  to  resort  to  this  anaesthetic  at  an  earlier  period 
than  usual.  Ether,  however,  was  not  safe,  and  its  use  in  such 
cases  was  to  be  condemned.  He  then  goes  on  to  report  a  case 
in  which  he  considered  that  chloroform  was  a  protection 
rather  than  a  dangerous  or  injurious  agent.  The  woman, 
when  received  into  the  lying-in  ward,  was  in  the  advanced 
stages  of  valvular  disease  of  the  heart,  with  marked  dropsy, 
dyspnoea,  etc.,  and  was  successfully  delivered,  and  rapidly  im- 
proved after  her  labor."  The  author  of  the  paper  stated  in 
conclusion,  that  in  chloroform  poisoning  particularly,  he  be- 
lieved it  was  best  to  rely  on  artificial  respiration,  which  was 
safe  and  efficient,  while  stimulation  of  the  phrenic  nerve  was 
not  safe.  The  hypodermic  injection  of  ammonia,  alcoholic 
stimulus,  etc.,  might  also  be  employed.  In  regard  to  chloro- 
form, Simpson  was  the  first  to  show  that  it  was  much  more 
of  a  local  anaesthetic  than  other  drugs  of  its  class.  The 
local  effect  of  ether  was  simply  one  of  freezing,  on  account  of 


438  ARTIFICIAL   ANiESTHESIA. 

its  rapid  evaporation.  There  is  one  very  important  agency 
which  should  never  be  omitted  in  arresting  respiration  from 
cliloroform — that  is,  flagellation  with  a  towel  dipped  in  ice 
water  applied  to  the  chest  and  back,  and  artificial  respiration. 

In  our  own  experience,  and  after  our  experiments,  we  would 
limit  the  use  of  this  most  potent  of  all  the  auresthetics  to  very 
young  children,  or  to  those  who  are  weak,  strumous  or  overgrown  ; 
to  puerperal  eclampsia,  in  very  violent  convulsions,  in  male 
adults,  or  in  females  during  delivery,  where  rapidity  of  dila- 
tation of  the  OS  uteri  is  absolutely  necessary  to  save  the 
mother's  life. 

In  some  rare  cases  of  painful  operation,  where,  after  con- 
tinued efforts,  no  complete  insensibility  can  be  produced  by 
ether,  we  would  feel  justified  in  the  use  of  chloroform,  on  a 
clean  sponge  or  inhaler.  By  a  reference  to  the  recent  cases 
of  deaths  from  this  agent,  we  are  fully  satisfied  that  no  amount 
of  care  or  precaution,  or  mode  of  administration,  or  amount 
inhaled,  will  prevent,  in  certain  cases,  the  fatal  result;  and 
yet  physicians  and  others  will  resort  to  the  use  of  chloroform, 
on  account  of  its  pleasant  taste  and  odor,  rapidity  of  action, 
cost  and  comparative  bulk. 

In  the  recent  admirable  work  on  surgery  by  Erichsen,  he 
discu?sed  the  question,  "  Do  antesthetics  influence  the  rate  of 
mortality  after  operation  ?  "  and  concludes  by  stating  :  "  I  am 
inclined  to  believe  that  the  rate  of  mortality  has  increased 
since  the  use  of  anajsthetics  in  operative  surgery."  Again,  "  I 
cannot  but  think  that  chloroform  does  exercise  a  noxious  in- 
fluence on  the  constitution,  and  does  lessen  the  prospect  of 
recovery  in  certain  states  of  the  system,  more  especially  when 
the  blood  is  in  an  unhealthy  state."  He  states  the  most 
dangerous  condition  in  which  chloroform  should  be  adminis- 
tered, is  that  in  consequence  of  renal  disease,  the  blood  is  loaded 
with  urea;  in  such  cases,  epileptiform  convulsions  are  readily 
induced. 

In  the  recent  work  of  Professor  Billroth,  of  Vienna,  he 
states:  "  Recently,  etber  has  come  more  into  use, on  account  of 
the  number  of  deaths  from  chloroform.  I  now  use  a  composi- 
tion of  three  parts  chloroform,  one  sulphuric  ether,  and  one 


ADMINISTRATION   OF   CHLOROFORM.  439 

absolute  alcohol,  which  seems   les3  dangerous  than   chloro- 
form." 

Mode  of  Administering-    Cliloroform  by  Inhalers, 

Etc. 

When  chloroform  was  first  discovered,  the  apparatus  em- 
ployed was  like  that  designed  for  etherization,  but  of  a  more 
reduced  size.  The  less  volatile  nature  of  chloroform,  permits 
even  the  abandonment  of  all  apparatus,  and  most  physi- 
cians prefer  to  use  a  handkerchief  or  a  compress,  folded  in 
several  thicknesses.  After  having  arranged  the  folds  in  cup- 
shape,  you  pour  on  the  linen  several  drops  of  chloroform,  and 
apply  it  over  the  mouth  aad  nostrils  of  the  patient,  allowing, 
however,  enough  free  space  for  the  atmospheric  air  to  enter 
freely  with  the  chloroform. 

If  the  subject  be  nervous,  irritable,  and  manifests  a  feeling 
of  suffocation,  remove  the  handkerchief  or  compress,  still  farther 
from  the  nostrils,  accustoming  the  patient,  little  by  little,  to 
the  odor  of  chloroform.  If  the  quantity  of  chloroform  does 
not  suffice,  renew  it  as  often  as  is  necessary,  always  observing 
the  same  precautions.    ■ 

This  method  is  certainly  simple,  although  it  has  its  disad- 
vantages. In  the  first  place,  it  conceals  the  face  of  the  pa- 
tient, and  prevents  the  surgeon  from  observing  in  the  physiog- 
nomy, the  effect  of  the  anaesthetic.  In  the  second  place,  it 
necessitates  the  use  of  a  greater  quantity  of  chloroform,  of 
which  a  great  deal,  after  having  soaked  through  the  entire 
compress,  is  lost  by  evaporation  from  its  external  surface. 

An  effort  has  been  made  to  overcome,  or  diminish,  these  dis- 
advantages, by  the  use  of,  very  simple  apparatus. 

It  was  necessary  to  fulfill  two  requirements — to  have  an  ab- 
sorbent surface,  on  which  to  pour  the  chloroform,  and  to  per- 
mit the  access  of  the  air,  which  must  be  mingled  with  the 
anaesthetic  vapors.  The  apparatus  of  Raynaud,  (of  Talon)  and 
Charriere,  fulfilled  these  requirements  pretty  well.  It  was 
composed  of  a  conical  horn  of  pasteboard,  pierced  by  a  large 
opening  at  the  top,  and  terminating  in  a  sort  of  mouth-piece, 
which  fitted  over  the  mouth,  and  nose,  of  the  patient.     The  ap- 


440  ARTIFICIAL   ANiESTHESIA. 

paratus  is  lined  on  the  inside  with  wool,  and  at  a  certain  dis- 
tance from  the  top  of  the  cone  is  a  diaphragm,  formed  by  sev- 
eral folds  of  wool,  presenting  in  the  centre  a  large  hole 
for  the  entrance  of  atmospheric  air.  It  is  upon  this  dia- 
phragm, that  the  chloroform  is  poured. 

The  anaesthetic  horn  of  Raynaud,  has  the  disadvantage  of 
leaving  much  to  be  desired  in  the  way  of  cleanliness.  Patients 
very  often  expectorate  into  the  interior  of  the  apparatus,  in  that 
stage  which  the  French  call  sputation  "  Le  Fort  Malgaignes."  * 
A  chloroform  inhaler  much  used  in  England  is  exempt  from 
this  objection.  It  consists  of  a  kind  of  metallic  box,  with  the 
margin  hollowed  out  in  the  parts,  which  correspond  to  the  nose 
and  chin  of  the  patient,  and  of  which  the  bottom  and  lower 
wall  are  pierced  by  a  hole,  permitting  the  entrance  of  air. 
An  attaohment  in  the  shape  of  a  horse-shoe,  fastened  to  the 
upper  wall  in  the  interior  of  the  apparatus,  permits  the  firm 
adjustment  of  several  rolls  of  linen,  or  two  bundles  of  lint,  on 
which  the  chloroform  is  poured.  The  linen,  or  lint,  is  re- 
newed each  time  the  box  is  used,  and  you  can  see,  that 
nothing  is  easier,  than  to  keep  the  apparatus  always  in  a  state 
of  perfect  cleanliness. 

Moreover,  the  least  change  in  the  physiognomy  of  the  pa- 
tient cannot  escape  the  eye  of  the  surgeon.  For  some  years 
past,  an  endeavor  has  been  made  to  substitute  for  the  com- 
press, some  rather  simple  apparatus,  consisting  principally  of 
a  piece  of  woolen  stuff  held  on  a  frame,  which  is  placed  at 
some  distance  in  front  of  the  mouth  (see  Skinner's  apparatus), 
as  a  sort  of  mask,  and  on  the  exterior  face  of  which  a  certain 
quantity  of  chloroform  is  poured,  drop  by  drop.  The  neces- 
Bity  of  allowing  the  patient  to  breathe  only  vapors  of  chloro- 
form, mingled  with  atmospheric  air,  has  led  to  the  construction 
of  several  appliances.  Clover,  had  the  idea,  of  preparing  be- 
forehand a  mixture  of  a  definite  quantity  of  air,  and  chloro- 
form. His  apparatus,  of  which  a  description  is  given  at  p.  140, 
is  composed  of  a  rubber  sack,  filled  by  means  of  a  special  kind 
of  a  bellows,  with  a  known  quantity  of  atmospheric  air,  with 

*  Translated  by  E.  M.  Hiestand,  Medical  Jleginter,  1888. 


APPARATUS  FOR  CHLOROFORM.         441 

which  is  mingled,  in  a  definite  proportion,  a  certain  amount  of 
chloroform,  in  such  a  way,  that  the  propoition  of  the  anaesthetic 
vapor  be  4.5  per  100  volumes  of  the  air  imprisoned  in  the  sack. 
For  several  years  this  mode  of  administering  chloroform  seemed 
to  give  complete  security,  but  from  1867  to  1874,  five  cases  of 
death  were  discovered  where  Clover's  apparatus  was  used,  the 
last  occurring  at  the  hands  of  Clover  himself. 

Snow's  apparatus,  and  that  of  Sansom,  have  disadvantages 
which  have  prevented  their  adoption.  Junker's  apparatus, 
merits  more  attention. 

It  is  composed  of  a  bottle  with  two  tubes  enveloped  in  steel, 
but  this  envelope  is  pierced  by  a  longitudinal  crack,  showing 
what  is  going  on  inside  the  bottle ;  and  has  a  graduated  scale, 
which  keeps  count  of  the  quantity  of  the  anaesthetic  em- 
ployed. 

A  hook  allows  the  operator  to  suspend  the  apparatus  from 
his  button-hole.  The  tube  conveys  to  the  bottom  of  the  bot- 
tle, the  air  which  is  forced  there  by  a  Eichardson  bellows. 
This  air,  after  having  mingled  with  the  chloroform,  passes  out 
by  an  attachment  and  through  the  tube  to  the  mouth-piece, 
which  is  placed  before  the  mouth  and  nose  of  the  patient. 

This  mouth-piece  of  hard  rubber,  has  a  valve  of  soft  rubber, 
which  opens  with  expiration,  and  closes  with  inspiration. 

A  movable  ring  placed  at  the  point  where  the  vapors  ar- 
rive, and  pierced  by  two  slits,  corresponding  to  two  openings  of 
the  same  calibre  in  the  attachment  which  prolongs  the  mouth- 
piece on  this  side,  allows  a  greater  or  less  quantity  of  pure  air 
to  reach  the  patient,  this  being  mingled  with  the  anaesthetic 
vapors  propelled  through  the  tube  into  the  mouth-piece. 
(Junker's  inhaler  for  chloroform,  modified  by  Dudley  Buxton 
Bee  p.  442.) 

Junker's  Inlialer. 

This  inhaler,  which  practical  acquaintance  with  its  imperfec- 
tion has  led  us  to  modify,  is  of  value,  though  it  must  not  be 
supposed  that  by  its  use  the  patient  is  placed  outside  the  range 
of  possible  danger.  In  this  apparatus,  half  an  ounce  of  chlo- 
roform is  poured  into  a  bottle,  through  a  funnel-shaped  opening 

19* 


442 


ARTIFICIAL  ANAESTHESIA. 


fixed  in  a  screw  top ;  air  is  then  pumped  through  the  chloroform, 
and  in  its  passage,  takes  up  the  vapor.  The  foot  bellows  are 
fixed  by  straps,  one  of  which  slips  over  the  toes,  while  the 
other  receives  the  heel  in  the  long  loop.  When  the  foot  presses 
lightly,  the  air  in  the  bellows  is  forced  through  the  tube  into 
the  bottle,  thence  through  another  tube  to  a  face-piece.  The 
net-enclosed  ball,  is  for  equalizing  the  stream  of  air  and  the 

Plate  40. 


JUNKER  S  INHALER  FOR  CHLOROFORM. 

Improved  by  Dudley  Buxton. 

avoidance  of  splashing.  It  is  important  not  to  put  more  than 
half  an  ounce  in  the  bottle  at  once,  and  not  to  pump  in  air, 
spasmodically,  or  too  forcibly,  otherwise  chloroform  may  be 
driven  through  the  system  of  tubes  into  the  face-piece.  Even 
if  this  should  not  happen,  a  strong  blast  of  chloroform-impreg- 
nated air  is  very  unpleasant,  and  deleterious,  if  allowed  to  im- 


EESPONSIBILITY   OF   PHYSICIANS.  443 

pinge  upon  the  face.  Whea  the  bottle  has  become  nearly  empty 
the  mill-headed  stopper  which  closes  the  funnel  is  removed,  and 
more  chloroform  added ;  thus  the  apparatus  need  never  be  un- 
hooked from  the  administrator's  coat,  and  the  top  never  un- 
screwed until  the  administration  is  over,  when  the  bottle  should 
be  emptied  and  cleaned. 


CHAPTEE    XXI. 

The  Legal  Responsibility  of  Physicians  in  the  Administration  of  Anses- 
thetics — Medico-legal  Relations  of  Anassthetics —  Case  in  Phila- 
delphia of  a  Surgeon  Dentist — The  Important  Question  whether 
Chloroform  can  be  Administered  for  Criminal  Purposes  ? — Cases 
in  France,  England  and  the  United  States— Dr.  N.  L.  Folsom, 
R.  M.  Denig— Chloroform  as  a  Poison — The  Chloroform  Habit. 

On  the  Leg-al  Responsibility  of  Physicians  in  the 
Administration  of  Ansesthetics. 

It  is  a  noted  fact,  that  when  anaesthetics  are  trusted  in  the 
hands  of  an  educated  and  careful  surgeon,  the  mortality  from 
their  use,  is  reduced  to  the  minimum.  The  individual  who  ad- 
ministers the  anaesthetic,  should  have  nothing  else  to  do  ;  his 
hands,  eyes  and  mind  should  be  on  this  alone.  In  our  hospitals, 
clinical  assistants  should  be  instructed  in  the  chemical,  physi- 
ological, and  toxicological  nature  of  anaesthetic  agents,  and  after 
being  thoroughly  trained  in  their  use,  and  in  the  means  of  re- 
suscitation, receive  a  certificate  of  competency.*  It  is  too  often 
the  case  that  valuable  lives  are  placed,  as  it  were,  in  the  hands 
of  young  men,  who  have  no  proper  knowledge  of  their  use,  and 
who  do  not  appreciate  the  great  responsibility  under  which  they 
are  laboring.  Such  powerful  agents  as  chloroform  and  ether,  or 
their  compounds,  should  be  handled  with  skill,  judgment  and 
discretion,  fully  realizing  that  on  the  exercise  of  these,  depends 
the  life  of  the  patient.  There  is  no  doubt,  that  many  deaths  have 
been  caused  through  the  want  of  this  proper  knowledge  and 
experience.     Who  is  at  fault  in  this  ?     It  is,  as  a  rule,  the  fault 

*  This  is  done  in  the  Philadelphia  Dental  College. 


444  ARTIFICIAL  ANiESTHESIA. 

of  the  operating  surgeon,  who,  in  a  general  way,  considers  this 
as  a  secondary  matter,  and  trusts  the  anresthetic  to  any  person 
who  may  be  with  him.  To  the  experienced  eye,  signs  of  danger 
are  almost  always  evident — the  disturbed,  stertorous,  or  shal- 
low respiration,  the  pulse,  the  pallid  or  leaden  hue  of  the  skin, 
the  fluttering  heart. 

We  repeat  it,  that  a  physician  or  a  surgeon,  in  administering 
ether  and  chloroform,  or  their  compounds,  is  responsible  for  the 
life  of  the  patient,  and  it  would  be  well  for  some  of  them  if  a  law 
were  enacted,  compelling  them  to  employ  the  least  fatal  anaes- 
thetic, unless  some  idiosyncrasy  on  the  part  of  the  patient  did 
not  allow  of  the  use  of  such  an  agent,  or  one  less  dangerous. 
Again,  in  our  navy,  especially  on  board  steamers,  and  in  coun- 
tries where  the  average  temperature  is  80°  F.  or  over,  chloro- 
form might  be  allowed,  but  in  the  army  in  the  field,  as  well  as 
in  the  navy,  only  in  capital,  or  very  painful,  or  extensive 
operations,  this  exception  being  enforced  by  a  rule. 

Daniel  S.  Riddle,  Esq.,  New  York,  said,  as  regards  the  en- 
actment of  further  laws  on  this  subject,  it  was  not  necessary. 
There  are  sufficient  laws  already.  The  difficulty  is  in  enforc- 
ing them.  If  there  is  carelessness  on  the  part  of  the  doctor,  he 
should  be  held  responsible.  It  is  the  same  with  lawyers.  It 
belongs  to  the  profession  of  medicine,  to  say  whether  these 
agents  have  been  carelessly  used  ;  and  if  they  have  been  care- 
les^sly  used,  it  is  their  duty  to  pi'oduce,  as  well  as  indicate,  the 
person  who  uses  these  great  powers  carelessly.  "  If  we  law- 
yers," he  remarked  facetiously,  "  find  out  that  you  are  care- 
lessly using  these  things,  it  is  our  duty  to  pitch  in." 

Mr.  Coroner  EUinger,  thought  it  would  be  a  hard  matter  to 
hold  doctors  responsible,  because  it  is  difficult  to  state  scientifi- 
cally where  the  responsibility  can  rest.  It  ought  at  least  to  be 
shown  that  there  was  conscious  negligence  in  the  performance 
of  duty.  The  condition  of  the  patient  should  be  taken  into 
account,  and  that  mu!^t  be  left  to  the  discretion  and  knowledge 
of  the  attending  surgeon.  He  thought  that  the  medical  stu- 
dent ought  to  be  taught  the  danger  of  the  agent  he  employs, 
how,  and  when  to  use  it  judiciously,  and  should  be  required 
to  secure  a  certificate  to  the  effect  that  he  has  been  so  instructed 


OPINIONS   OF.  DISTINGUISHED   MEN.  445 

before  beiog  let  loose  upon  the  public.  The  public  would  then 
know  that  he  possesses  a  knowledge  of  the  agent  which  he  em- 
ploys. Besides,  the  physician  would  be  conscious  of  a  certain 
moral  responsibility,  for  he  held  that  the  moral  responsibility 
which  every  medical  gentleman  must  feel,  is  greater  than  the 
responsibilities  placed  upon  him  by  the  laws  of  the  land. 

Jacob  F.  Miller,  Esq.,  agreed  with  those  who  advocated  care 
in  the  use  of  these  agents.  Man  is  living  in  the  midst  of  dan- 
gerous forces,  and  will  continue  to  use  them,  though  of  neces- 
sity many  deaths  occur.  But  in  order  to  rest  a  case  against 
the  user,  it  is  necessary  to  show  negligence.  Negligence,  is  the 
gist  of  the  action.  The  physician,  surgeon  or  lawyer  contracts 
for  the  ordinary  skill,  and  care  of  his  profession.  He  does  not 
contract  for  any  extraordinary  skill.  The  law  does  not  hold 
him  any  more  responsible  than  that.  It  would  be  unreasona- 
ble to  do  so,  because  few  persons  could  safely  practice  their 
profession;  and  if  any  person  should  use  ansesthetics,  and  the 
patient  should  die,  that  is  not  sufficient  to  charge  him  with 
the  responsibility.  He  thought,  that  all  would  admit,  that  if  a 
man  not  having  the  ordinary  skill  of  his  profession,  should,  by 
unskillful  administration  of  antesthetics,  cause  the  death  of  the 
patient,  he  should  be  prevented  from  doing  further  damage  by 
a  suit  for  malpractice.  Would  it  not  be  better  to  stop  him  by 
such  procedure  ?  Shall  a  man  be  allowed  to  use  such  danger- 
ous forces  just  as  he  pleases — let  the  consequences  be  what 
they  may?  People  consult  physicians,  because  they  say  they 
have  the  requisite  skill  to  use  these  things.  They  hold  them- 
selves out  to  the  community  as  having  this  skill,  and  they 
ought  to  possess  it;  if  they  do  not,  and  harm  results  from  it, 
they  ought  to  be  held  responsible.  The  coroner  says,  that 
physicians  are  actuated  by  moral  responsibility,  which  is  no 
responsibility  at  all.  The  quack  will  go  on  with  his  practices, 
until  he  is  stopped  by  the  law.  Where  is  his  moral  responsi- 
bility? What  does  he  care?  His  practice,  only  goes  to  show 
that  he  has  no  moral  responsibility.  That  lawyers  should  check 
such  practices,  is  due  to  the  profession,  to  the  public,  and  to  God. 
But  before  they  take  a  case  of  malpractice,  they  ought  to  be  con- 
vinced that  there  is  malpractice.    It  may  be  all  very  well  to  say 


446  ARTIFICIAL   ANAESTHESIA. 

that  negligence  is  the  gist  of  an  action.  If  it  cannot  be  shown 
that  there  is  negligence,  the  case  should  not  be  taken,  for  when 
the  case  arrives  at  the  courts,  you  must  show  that  the  defendant 
is  guilty  of  neglect,  and  that  is  done  by  calling  upon  a  physician 
who  is  able  to  say  where  negligence  has  been  committed,  and 
that  he  is  guilty  of  it.  This  evidence  is  necessary ;  lawyers 
cannot  get  along  without  it. 

Mr.  Max  F.  Eller  spoke  of  the  fact  that,  for  any  action,  as 
many  "  experts  "  could  be  obtained  by  one  side  as  the  other, 
provided  enough  money  is  paid  for  such  expert  testimony. 
Some  will  say,  the  patient  should  have  been  notified  of  the 
danger;  others,  that  he  ought  not.  Some  will  say,  the  chloro- 
form killed  him  ;  others,  not.  For  that  reason,  he  thought  that 
before  making  any  more  laws  regarding  the  proper  administra- 
tion of  anaesthetics,  those  which  already  exist  should  be  ad- 
ministered in  a  better  manner,  and  physicians  should  be  a  little 
more  careful  how  they  administer  auossthetics. 

Mr.  Eller,  referred  to  the  popular  fallacy  that  chloroform 
could  be  used  successfully  for  the  purpose  of  effecting  rob- 
bery. He  thought,  that  that  delusion  ought  to  be  dispelled, 
for  the  time  between  the  actual  administration  of  chloroform, 
and  the  period  of  annihilation  of  sensation,  is  sufficiently  long 
to  render  the  accomplishment  of  the  object  impossible.  Such 
a  plea  is  used  by  criminals,  to  shield  themselves  from  the  con- 
sequences of  their  own  crimes. 

A  correspondent  of  the  Societe  d' Hygiene  et  de  Medieine  Legal, 
having  been  interrogated  as  a  judicial  expert,  as  to  "  whether 
the  employment  of  narcotics,  in  the  liquid,  or  gaseous  state,  can 
produce  an  ansesthesia  so  profound  that  violation  of  the  per- 
sons to  whom  it  has  been  given,  may  be  perpetrated,  without 
awakening  them,"  gave  an  affirmative  answer. 

M.  Dolbeau,  apropos  to  his  judgment,  made  a  series  of  re- 
searches, the  results  of  which  were  laid  before  the  society. 
He  limits  the  question  to  the  employment  of  chloroform,  and 
starts  with  the  following  proposition  : 

"  Can  chloroform  in  vapor  be  administered  to  a  person  who  is 
sleeping  naturally,  to  the  production  of  anoisthesia,  without  awaken- 
iag  him  f  " 


CHLOROFORM   GIVEN   DURING   SLEEP.  447 

In  M.  Dolbeau's  experiments,  the  chloroform  was  given  in 
the  usual  manner,  on  a  cone  held  an  inch  or  so  above  the  nos- 
trils, so  as  to  enable  a  constant  view  of  the  countenance. 

In  the  first  series  of  experiments,  three  patients  out  of  four 
were  awakened  by  the  chloroform  inhalations ;  in  the  second 
series,  four  out  of  six ;  in  the  third,  only  three  out  of 
nine. 

It  is  not  without  interest  to  observe  the  increasing  proportion 
of  subjects  anaesthetized;  the  manual  dexterity  acquired  by 
the  experiments  is  not  without  influence  upon  the  results  ob- 
tained. Accordingly,  as  a  result  of  his  experiments,  M.  Dol- 
beau  believes  himself  authorized  to  formulate  the  following 
conclusions : 

"  Scientifically,  it  is  diflicult,  but  often  possible,  to  cause  in- 
sensibility by  means  of  chloroform,  in  persons  who  are  sleeping 
a  natural  sleep.  Certain  precautions — the  employment  of  a 
perfectly  pure  agent,  and  experience — are  also  conditions  which 
favor  the  attempt  at  anaesthesia. 

"  It  is  probable  that  certain  subjects  are  absolutely  refractory 
— that  is  to  say,  that  it  is  imposssible  to  anaesthetize  them,  with- 
out taking  every  precaution.  Others,  on  the  contrary,  par- 
ticularly young  children,  submit  easily  to  anaesthesia  without 
having  been  awakened  by  the  irritation  produced  by  the  an- 
aesthetic agent  in  the  air-passages. 

"  From  a  criminal  point  of  view,  it  is  certain  that  chloroform, 
administered  to  sleeping  individuals,  may  facilitate  the  perpe- 
tration of  certain  crimes.  It  is,  however,  probable,  that  the 
conditions  favorable  to  anaesthesia  are  rarely  found  on  the  oc- 
casion of  criminal  attempis.  In  justice,  the  expert  should  de- 
clare, that  it  is  possible,  but  not  easy,  to  render  a  person  who 
sleeps  so  insensible  by  chloroform,  that  the  said  person  might 
become  the  victim  of  any  violence. 

"  The  responsibility  attending  the  use  of  anaesthetics  is  of  great 
importance  to  medical  men,  as  frequently  their  personal,  and 
professional,  reputation  is  at  stake ;  it  is  therefore  always  better, 
in  the  administration  of  an  anaesthetic  to  a  female,  to  have  some 
reliable  person  present.  This  is  especially  necessary,  when 
ether,  or  chloroform,  is  employed." 


448  ARTIFICIAL   ANESTHESIA. 

During  the  early  period  of  our  medical  career,  soon  after 
graduating,  we  had  in  our  Quiz  class  a  young,  ambitious  dental 
surgeon,  one  of  the  most  gentle  and  amiable  of  men,  who  was 
desirous  of  obtaining  the  medical  degree,  which  he  ulti- 
mately attained.  Soon  after  this  the  man  was  married,  settled 
in  this  city,  and  acquired  a  large  business.  At  that  time  it 
was  common  for  the  dentist  to  administer  anaesthetics  in 
their  office,  in  the  extracting  of  teeth,  etc.  He  had  a  young 
female  patient  to  whom  he  administered  chloroform  alone, 
and  who  afterwards  stated  that  he  had  taken  improper 
liberties  with  her  person,  during  this  state.  This  case  caused 
great  excitement  in  our  city,  and  the  public  sympathy  was 
with  the  young  female,  and  a  suit  was  instituted  iu  which 
damages  were  claimed.  The  case  was  argued  by  distinguished 
lawyers  on  both  sides,  and  voluminous  testimony  taken.  The 
judge  charged  the  jury,  and  the  sentence  was  ten  years'  im- 
prisonment. Subsequently  the  sentiment  of  the  community 
changed,  and  it  believed  it  was  all  the  result  of  her  vivid 
imagination,  and  that  she  was  lal)oring  under  a  delusion. 
The  majority  of  physicians  and  dentists  signed  a  petition,  and 
the  sentence  was  remitted. 

It  is  stated  by  Taylor  "  That  the  vapors  of  ether  and  chloro- 
form have  been  criminally  used  in  attempt  at  rape.  In  a  case 
which  occurred  in  France,  a  dentist  was  convicted  of  this  crime 
upon  a  woman  to  whom  he  had  administered  the  vapor  of 
ether."  Now  this  may  be  just  such  a  case  as  the  one  in  our 
own  city.  Ether,  from  its  disagreeable  taste  and  irritating  va- 
por, would  be  much  more  difficult  to  administer  forcibly  and 
against  the  will  of  a  patient.  The  numerous  stories  of  anaes- 
thesia by  simply  placing  a  few  drops  on  a  handkerchief  under 
a  patient's  nose  or  mouth,  are  in  the  majority  of  cases,  perfectly 
absurd,  as  the  shortest  time  required  to  bring  a  patient  fully 
under  the  influence  of  either  of  these  drugs — even  when  forci- 
bly held  in  contact — is,  from  two,  to  ten  minutes,  and  if  subse- 
quent rough  handling  takes  place,  the  patient  is  at  once  roused 
to  make  resistance  ley  struggling.  We  were  once  called  to  a 
woman  who  had  been  in  the  habit  of  employing  chloroform  by 
inhalation  from  a  small  bottle  to  cause  sleep  ;  she  accidentally, 


CHLOROFOEM  FOR  IMPROPER  PURPOSES.    449 

when  in  a  drowsy  state,  let  the  open  bottle,  drop  on  the  pillow, 
and  its  contents  saturated  the  covering,  and  she  lay  with  her  face 
in  it.  But  instead  of  making  her  sleep  soundly,  it  produced 
most  distressing  nausea,  and  her  family  were  awakened  by  her 
eiforts  at  vomiting,  and  so  her  life  was  saved,  she  not  being 
able  to  arouse  suflficiently,  to  get  rid  of  the  oifending  matter, 
which  would  have  lodged  in  her  trachea,  or  the  contents  of  the 
stomach  might  have  been  brought  into  the  bronchial  tubes  by 
deep  inspiration,  and  thus  have  caused  suffocation. 

The  former  case  in  Philadelphia,  settled  the  important  point 
in  the  minds  of  medical  men  of  this  city,  that  this  incomplete 
unconsciousness,  does  not,  coexist  with  complete  motor  and  sen- 
sory anaesthesia,  and  therefore  anaesthetics  are  employed  with- 
out any  fear  in  all  important  operations.  These  observations, 
are  in  part  corroborated,  by  two  learned  authors,  in  a  recent  and 
most  admirable  work,  on  medical  jurisprudence,  in  which  they 
state : — 

"A  question  of  some  importance  to  the  medical  jurist  natur- 
ally occurs  here,  namely :  '  Whether  chloroform  can  be  adminis- 
tered for  improper  purposes  f '  We  know,  however,  that  insensi- 
bility from  chloroform,  (and  more  slowly  from  ether)  vapor,  is 
only  slowly  induced.  It  would  be  difficult,  therefore,  to  admin- 
ister chloroform  forcibly,  and  against  the  will,  while,  of  course, 
the  stories  of  immediate  anaesthesia  produced  by  it,  are  but  idle 
fables.  Still,  it  might  be  administered  to  persons  asleep,  with- 
out much  difficulty,  and  this  seems  the  only  possible  condition 
under  which  it  could  be  conveniently  used  for  improper  pur- 
poses, unless  considerable  force  was  employed  to  prevent  the 
person  struggling,  which,  under  ordinary  circumstances,  would 
be  an  almost  insurmountable  difficulty  to  its  use." 

The  following  case  (reported  in  the  Philadelphia  Medical 
Times,  December  22d,  1877),  which  occurred  in  England,  more 
completely  confirms  our  own  observations  and  experiments  on 
this  important  subject : — 

"  A  case  of  the  utmost  importance  to  the  Avhole  profession, 
not  in  Great  Britain  only,  but  everywhere,  was  tried  before 
Mr.  Justice  Hawkins,  at  the  assizes,  at  Northampton,  on  the 
9th  of  November.     It  was  a  charge  against  a  surgeon's  assist- 


450  autificial  anaesthesia. 

ant  of  criminal  assault — of  rape  upon  a  patient,  when  under  the 
influence  of  chloroform.  If  there  is  a  dastardly  crime,  it  is  to 
take  advantage  of  a  woman's  helpless  unconsciousness  to  vio- 
late her  person.  And  so  the  magistrate  thought,  who  sent  the 
accused  to  jail  on  the  14th  of  September,  declining  to  hear 
anything  in  his  favor,  and  resolutely  refusing  to  accept  bail. 
The  charge  was,  that  a  married  woman,  named  Child,  went  to 
the  surgery  of  her  family  medical  attendant,  to  have  her  teeth 
operated  upon.  She  had  been  there  a  day  or  two  before,  but 
the  attempt  to  put  her  under  chloroform  then  failed.  A  second 
attempt  was  rather  more  successful.  She  evidently  had  some 
peculiarities,  or  idiosyncrasies,  in  relation  to  chloroform,  for  he 
gave  it  for  an  hour,  and  yet  she  was  never  sufficiently  under  its 
influence  to  admit  of  the  operation  being  performed.  She  was 
accompanied  by  a  friend — a  Miss  Fellows.  At  the  end  of 
the  hour.  Miss  Fellows  went  out  of  the  room.  In  a  quarter 
of  an  hour  Miss  Fellows  returned.  The  prosecutor  main- 
tained, that  on  Miss  Fellows'  return,  she  was  quite  con- 
scious, but  unable  to  speak.  Finding  it  impossible  to  perform 
the  operation,  the  accused  accompanied  the  prosecutrix,  and 
her  friend  home.  So  far  Mrs.  Child  had  been  unable  to  speak, 
but  shortly  after  the  accused  left  the  house  she  complained  to 
her  husband  that  he  had  taken  advantage  of  the  absence  of 
Miss  Fellows,  to  assault  her  criminally.  Next  day,  when  the 
accused  called,  he  was  told  about  what  she  had  said,  and  he  re- 
plied that  she  was  laboring  under  a  delusion.  Under  cross-ex- 
amination, Mrs.  Child  said,  that  she  told  the  accused  that  if  he 
would  admit  the  oflfence  and  quit  the  town  (Birmingham)  she 
would  forgive  him.  This  the  accused  declined  to  do,  denying 
that  he  had  committed  any  ofience.  He  was  then  given  in  cus- 
tody. The  prosecutrix  stated  that  the  off"ence  was  perpetrated 
immediately  after  Miss  Fellows  left  the  room  ;  that  the  prisoner 
went  upon  his  knee?,  and  then  assaulted  her.  Miss  Fellows 
stated  that  on  her  return,  she  found  Mrs.  Child  in  precisely  the 
same  position  in  the  chair  which  she  occupied  when  she  went 
out  of  the  room.  Such  were  the  facts  of  the  case.  It  was  quite 
clear  that  there  had  been  either  an  assault  committed,  or  that 
the  woman  was  under  the  influence  of  a  very  pronounced  delu- 


THE  IMPORTANCE  OF  A  PERSON  PRESENT.   451 

sion.  The  wliole  of  tlie  accused's  conduct  was  ia  favor  of  the 
latter  hypothesis.  But  in  such  a  matter,  where  no  third  person 
was  present,  the  statement  of  one  of  the  two  parties  concerned 
must  be  taken.  When  a  woman  whose  character  was  appar- 
ently without  blemish,  (for  in  cross-examination  no  attempt  was 
made  to  call  her  reputation  in  question)  makes  a  definite  charge 
against  a  man,  of  assaulting  her  under  circumstances  which 
permitted  of  such  an  assault,  the  law  could  only  send  the  case 
to  a  jury.  In  the  meantime  the  unfortunate  surgeon's  assist- 
ant, was  sent  to  prison. 

"  When  the  case  came  to  be  tried  a  large  number  of  medical 
men  of  repute  came  forward  voluntarily,  to  aid  the  accused's 
defence,  and  did  this  quite  gratuitously.  The  chief  witness  for 
the  defence  was  Dr.  B,  W.  Richardson,  F.R.S.,  whose  celebrity 
is  world-wide.  As  is  well  known.  Dr.  Richardson  has  studied 
anaesthetics  very  carefully,  and  for  many  years.  He  stated  that 
there  were  four  stages,  or  degrees,  in  which  chloroform  operated. 
The  first  stage  was  that  in  which  consciousness  was  not  lost ; 
there  was  resistance  and  a  desire  for  air.  In  the  second,  con- 
sciousness is  lost,  but  the  operation  is  impossible,  the  patient 
screaming,  often  without  provocation.  The  third  stage,  is  that 
of  complete  unconsciousness,  and  where  all  rigidity  is  lost. 
This  is  the  stage  which  permits  of  operation.  In  his  opinion, 
the  patient  was  in  the  second  stage ;  the  third,  never  having 
been  reached.  He  stated,  that  in  his  own  experience,  he  had 
known  persons  in  this  second  stage,  to  have  delusions  as  to  what 
had  taken  place  during  that  time.  He  related  a  number  of 
cases,  and  stated,  that  the  fact  of  such  delusions  being  induced 
by  chloroform,  was  one  of  the  earliest  objections  raised  to  its 
adoption.  He  related  one  case,  where  the  patient,  a  female, 
was  being  operated  upon  by  a  dentist,  and  alleged  that  the 
dentist  criminally  assaulted  her.  And  this  she  persisted  in, 
though  her  father,  her  mother.  Dr.  Richardson,  and  the  den- 
tist's assistant  were  all  present,  throughout  the  whole  time. 
She  persisted  in  her  conviction  long  after  the  effects  of  the 
chloroform  had  passed  away ;  and  Dr.  Richardson  said  she  was 
probably  of  that  belief  still.  This  evidence  of  Dr.  Richard- 
son's, was  corroborated  by  the  experience  of  Dr.   Hawksby,  ot 


452  ARTIFICIAL   ANAESTHESIA. 

Londou,  and  by  Dr.  Saundby,  and  Mr.  J.  F.  West,  of  Birming- 
ham. The  judge  asked  the  jury  if  it  was  necessary  to  sum  up, 
and  they  replied  it  was  unnecessary — they  were  already  agreed 
upon  a  verdict  of  acquittal.  Mr.  Justice  Hawkins  pointed  out 
that  such  a  verdict  would  not  be  the  slightest  imputation  upon 
the  absolute  sincerity  of  the  prosecutrix,  who,  no  doubt,  firmly 
believed  every  word  of  what  she  had  said.  He  then  congratu- 
lated the  accused,  upon  having  had  an  opportunity  of  fully 
vindicating  himself  from  the  charge  preferred,  and  said  that 
the  verdict  of  acquittal  did  not  mean  that  there  was  insuffi- 
cient evidence,  but  that  the  accused  was  entirely  cleared  of 
any  imputation  in  respect  to  the  charge  preferred  against  him. 
There  could  be  no  doubt  the  prosecutrix  labored  under  a  delu- 
sion. The  accused  was  then  discharged  from  custody,  having 
been  in  prison  two  months  for  no  offence.  It  is  not  merely 
that  this  unfortunate  man  was  imprisoned  for  two  months  for 
an  imaginary  offence,  but  that  any  man  who  is  present  when 
a  woman  is  being  put  under  chloroform,  is  liable  to  have  the 
same  charge  brought  against  him,  that  gives  this  case  its 
gravity  and  importance. 

"  Such  being  the  case,  it  becomes  necessary  that  a  little 
more  should  be  known  amidst  the  profession,  as  well  as 
the  laity,  as  to  the  occurrence  of  erotic  sensations  in  woman. 
The  subject  is  not  a  pleasant  one,  but  that  is  no  reason 
why  it  should  not  be  investigated.  If  it  is  a  fact,  and  there 
is  no  doubt  about  this,  that  women,  when  being  put  under 
chloroform,  are  liable  to  those  erotic  sensations  which  they 
experience  from  sexual  intercourse,  the  sooner  the  fact  is 
generally  known,  the  better.  It  is  just  the  mystery  which 
surrounds  such  facts,  that  permits  such  a  monstrous  hard- 
ship as  that  mentioned  above,  to  be  a  possibility  at  all.  Of 
course  it  is  obvious  enough  to  any  one,  that  it  is  a  delicate 
matter  to  inquire  into  the  subjective  sensations  of  women. 
But,  if  these  subjective  sensations  take  the  practical  form  of  a 
charge  of  rape,  two  months  in  jail,  and  a  trial  by  jury,  they 
pass  from  the  domain  of  sentiment,  and  enter  that  of  stern 
reality.  Few,  comparatively  few,  of  the  profession  seem  to 
be  aware  that  women  are  subject  to  conditions  and  sensations. 


THE   DELUSION   OF   ST.    CATHERINE,    ETC.        453 

identical  with  those  associated  with  the  sexual  act,  which 
arise  quite  subjectively  and  without  any  extrinsic  stimulus. 
The  delusion  of  St.  Catharine,  that  the  devil  visited  her  every 
night,  and  enjoyed  her  person  when  she  was  asleep,  and  could 
offer  no  resistance,  is  no  unique  experience,  but  one  common 
enough  to  women.  Every  one  familiar  with  asylum  work, 
knows  that  a  certain  percentage  of  women  patients  have  this 
delusion,  among  others,  that  the  medical  superintendent  comes 
nightly  to  their  bed,  and  violates  their  person  during  sleep. 
Of  course  there  is  no  foundation  of  any  kind  for  such  delu- 
sions, except  the  subjective  sensations  of  the  woman  herself. 
How  strongly  such  a  delusion,  however,  may  be  fixed  in  a 
woman's  mind,  is  evidenced  by  the  case  related  by  Dr.  Rich- 
ardson, where  the  woman  persisted  in  her  belief,  though  her 
own  father  and  mother,  as  well  as  others,  were  present,  and 
where  such  assault  was  physically  impossible.  Such  being 
the  case,  it  behooves  every  man  who  is  to  be  present  with  a 
woman  when  she  is  to  be  placed  under  chloroform  to  see  that 
there  is  at  least  one  other  person  present,  and  that,  too,  the 
whole  time,  without  intermission,  during  which  the  woman  is 
under  the  influence  of  chloroform,  and  that  such  other  pre- 
cautions be  taken  as  will  preclude  the  possibility  of  such  a 
charge  being  raised.  That  Mrs.  Child  charged  this  unlucky 
man  in  good  faith,  need  not  be  questioned  for  a  moment.  She 
was  far  from  being  hostile  to  him,  for  she  offered  if  he  would 
avow  his  guilt  and  leave  the  town,  she  would  forgive  him. 
The  charge  was  not  pressed  from  any  rancorous  spite ;  that  is 
abundantly  clear.  But  it  is  equally  clear  that  something  had 
occurred  to  that  woman  which  she  interpreted  into  the  sexual 
act,  and  that  this  was  so  firmly  fixed  in  her  consciousness, 
that  it  could  not  be  dislodged.  It  becomes  necessary,  then,  that 
the  subjective  sensations  of  women  should  be  investigated,  and 
made  the  subject  of  scientific  observations ;  and  seeing  that 
they  exist,  they  must  have  a  scientific  value ;  and  that  no 
prudishness  should  prevent  attempts  being  made  to  ascertain 
what  the  actual  facts  are,  and  what  is  their  interpretation." 

The  following  is  the  experience  of  Dr.  N.  L.  Folsom,  of 
Portsmouth,  New  Hampshire,  in  the  same  line  :— 


454  ARTIFICIAL  ANAESTHESIA. 

"In  1854,  a  clergyman's  sister  came  to  my  office  for  the  pur- 
pose of  taking  ether  and  having  a  tooth  extracted,  and  brought 
her  brother's  wife  with  her.  I  began  to  administer  the  ether 
to  the  patient,  and  whilst  renewing  it  she  got  away  from  me, 
and  seemed  alarmed  and  offended.  I  did  not  attempt  to  com- 
pel her  to  breathe  any  more  ether,  but  urged  her  to  take  it,  and 
80  also  did  her  brother's  wife,  but  she  would  take  no  more. 
She  had  the  impression,  so  her  brother  told  me,  that  I  at- 
tempted to  violate  her,  and  that  his  wife  assisted  me.  It  was 
a  long  time  afterward  before  she  would  fully  give  up  that  she 
was  mistaken  in  the  matter." 

We  are  almost  certain,  after  a  number  of  careful  experi- 
ments, that  chloroform  and  ether  can  be  administered  in  sleep, 
so  as  to  produce  the  first  stage  of  anjesthesia,  and  can  be  car- 
ried to  full  completion  or  total  unconsciousness.  Still,  this  is 
rare  without  disturbing  the  patient's  stomach,  causing  nausea, 
or  irritation  of  the  lungs,  with  risk  of  sudden  death,  by  its 
dense  vapor,  and  thus  rousing  him  or  her  to  consciousness,  or 
a  condition  in  which  the  patient  can  resist  its  influence  if  the 
party  is  willing  to  make  the  effort.  Another  important  point 
is,  that  loud  talking  or  handling,  even  in  some  cases  the  slight- 
est touch  or  pain  in  any  way,  will  cause  the  patient  to  start 
and  rouse  him  to  resist.  In  the  case  of  ether  the  patient  can 
almost  always  see  indistinctly,  and  in  some  instances  is  able  to 
talk  during  the  ansesthetic  state. 

Attention  has  been  directed  by  Dr.  J.  M.  Quimby,  of  Jer- 
sey City,  N.  J.,  to  certain  facts,  connected  with  the  use  and 
abuse  of  chloroform,  and  from  these  facts  inferences  have 
been  derived  which  may  be  interesting  and  instructive  to  the 
profession. 

He  states,  "  that  in  consequence  of  the  recent  murder  of  police- 
man Smith,  in  Jersey  City,  while  he  and  his  wife  were  sup- 
posed to  be  asleep  in  bed,  his  wife  was  arrested  as  a  particeps 
criminis.  She  denied  the  charge,  and  asserted  that  she  had 
been  chloroformed  during  sleep,  and  therefore  was  innocent  of 
the  crime. 

"  The  State  denied  this,  and  contended  that  it  was  impossible 
for  her  to  have  been  chloroformed  in  that  way;  that  the  fumes 


CIILOEOFOEM   IN   MUEDER.  455 

of  the  chloroform  would  have  certainly  awakened  her  from 
her  natural  sleep,  and  therefore  she  must  have  known  who  the 
murderer  or  murderers  were. 

"  Here,  then,  as  will  be  seen,  arose  a  very  nice  and  important 
medico-legal  question,  viz. :  whether  a  person  could  be  chloro- 
formed whilst  in  natural  slumber  without  first  being  awakened, 
or,  in  other  words,  whether  the  application  of  chloroform, 
properly  given,  would  awaken  the  person  to  whom  it  was  ap- 
plied ;  or,  could  such  person  pass  from  the  natural  to  an  arti- 
ficial sleep  (or  chloroform  sleep),  without  being  aroused  by  its 
application  ? 

"  Mrs.  Smith  asserted,  most  positively,  that  she  was  chloro- 
formed while  she  was  asleep  in  bed  with  her  husband,  and 
knew  nothing  about  the  murder,  until  she  awoke  in  a  bewil- 
dered condition,  feeling  the  cold  elbow  of  her  husband  pressing 
against  her  side.  It  may  be  stated  here,  that  there  was  found 
in  the  room  of  the  murdered  man  a  bottle  partly  filled  with 
chloroform,  and  a  folded  towel  with  bloody  finger-prints,  which 
Mrs.  Smith  asserted  was  upon  her  face  when  she  awoke.  She 
also  described,  quite  accurately,  the  taste,  smell  and  pungency 
of  chloroform. 

"  Without  going  into  further  details,  the  counsel  for  Mrs. 
Smith  applied  to  me  to  know  if  it  were  possible  to  transfer  a 
person  from  a  natural  to  an  artificial  sleep  by  the  use  of  chlo- 
roform without  first  arousing  the  sleeper  from  his  natural 
slumber?  I  replied,  that  I  had  never  attempted  the  applica- 
tion of  chloroform  to  a  person  while  in  a  natural  sleep,  and  that 
books,  as  far  as  I  knew,  were  silent  on  that  point;  although  I 
thought  there  would  be  no  difiiculty,  if  proper  care  were  taken 
in  administering  the  chloroform,  in  transferring  a  person  from 
the  natural  to  an  artificial  sleep. 

"  I  was  strongly  urged  on  the  part  of  Mrs.  Smith's  counsel, 
and  in  behalf  of  humanity  and  justice,  to  settle  by  experiment 
this  disputed  question.  To  accomplish  this  result  I  made  the 
following  experiments  :  I  made  arrangements  with  Mr.  A.,  to 
enter  his  room  in  an  hour  or  two  after  he  had  retired,  and 
when  he  was  asleep  apply  the  chloroform ;  which  I  did  with 
entire  success — transferring  him  from  the  natural,  to  the  chlo- 


456  ARTIFICIAL  ANAESTHESIA. 

roform  sleep  without  arousing  hira  from  his  natural  slumber. 
I  used  about  three  drachms  of  Squibb's  chloroform,  and  occu- 
pied about  seven  minutes  in  putting  him  to  sleep.  The  second 
case  was  a  boy,  tet.  13,  who  was  suffering  from  an  ingrowing 
toe-nail.  He  refused  to  allow  me  to  touch  hira  with  knife  or 
forceps  without  etherizing  hira;  and  when  I  attempted  to  apply 
the  ether,  he  screamed  and  struggled  so  desperately  that  his 
mother  became  frightened,  and  asked  me  to  desist  from  giving 
him  ether.  In  this  dilemma,  I  advised  the  mother  to  take  the 
boy  home  and  put  him  to  bed  with  a  light  supper,  and  I  would 
call  at  the  house  between  nine  and  ten  o'clock  that  evening, 
give  hira  a  little  chloroform,  and  remove  the  nail  without 
the  boy  knowing  anything  about  it. 

"  I  called  at  the  time  agreed  upon,  with  my  friend,  Dr.  Cahill, 
and  found  the  boy  quietly  sleeping.  I  applied  the  chloroform, 
divided  the  nail  in  the  centre,  and  removed  the  two  segments 
by  the  application  of  forceps,  without  awakening  the  patient, 
or  his  having  any  knowledge  of  the  operation  until  next  morn- 
ing when  he  awoke,  and,  discovering  the  condition  of  his  foot, 
remarked,  that  had  he  known  'it  would  not  hurt  any  more 
than  that,  he  would  have  had  it  taken  out  at  the  office,  and 
was  ashamed  that  he  had  made  such  a  fuss  about  it.' 

"Case  No.  3,  was  a  boy,  set.  10,  who  was  brought  to  my  office 
suffering  from  a  swelling  over  the  lower  jaw,  which  proved  to 
be  an  abscess  due  to  decayed  teeth  ;  but  the  boy  would  not  let 
me  come  near  hira  with  either  lancet  or  forceps  ;  so,  as  in  pre- 
vious cases,  I  advised  his  mother  to  take  him  home  and  send 
him  to  bed  with  a  light  supper,  and  that  I  would  call  at  the 
house  after  he  got  asleep,  administer  the  chloroform,  open  the 
abscess,  extract  the  teeth,  and  he  would  know  nothing  about 
it ;  all  of  which  I  did,  without  arousing  the  boy. 

"I  remained  with  the  patient  about  one  hour  after  the  opera- 
tion, to  attend  to  any  hemorrhage  that  might  occur,  and  to 
observe  if  any  change  would  take  place  when  he  would  pass 
from  his  artificial  to  his  natural  slumber  again. 

"  Finding  there  was  no  change  in  that  time,  I  left,  requesting 
the  parents  to  watch  him,  and  let  me  know  exactly  at  what 
hour  he  awoke. 


GIVE   CHLOROFORM  WITH   AN  ATTENDANT.      457 

"  When  I  called  next  morning,  they  reported  that  he  awoke  at 
six  o'clock,  exclaiming,  '  I  must  have  swallowed  my  teeth,  for 
they  are  both  gone ! '  " 

"  Bewaee  of  Chloroforming  Women  Without  an  At- 
tendant!—At  Oakland,  Cal.,  during  July,  1880,  a  bank- 
teller,  named  E,  F.  Schroeder,  killed  Dr.  Albert  Lefevre,  a 
prominent  dentist  of  that  place.  It  appears  that  Mrs.  Schroe- 
der went  to  the  train  on  the  day  of  the  shooting,  to  meet  her 
husband.  Mrs.  Schroeder  told  him,  that  on  the  Saturday  pre- 
vious, while  under  the  influence  of  chloroform  in  Dr.  Lefevre's 
office,  the  dentist  made  a  felonious  assault  upon  her.  Schroe- 
der at  once  proceeded  to  Dr.  Lefevre's  office,  and  committed 
the  tragedy.  It  is  believed  that  Mrs.  Schroder's  charge 
against  the  dentist  is  purely  illusory.  Such  hallucinations  are 
not  uncommon  after  chloroform  administrations.  Some 
remarkable  cases  exist,  where  hallucinations  of  this  nature 
have  taken  the  form  of  absolute  conviction  in  the  minds  of 
persons  laboring  under  them,  although  there  exists  abundant 
evidence  to  prove  that  this  conviction  was  utterly  unfounded. 
The  coroner's  jury  rendered  a  verdict  charging  Schroeder  with 
murder.  We  know  of  an  instance,  in  which  the  presence  of  a 
third  party,  saved  a  like  imputation  against  the  character  of  an 
innocent  practitioner.  The  lady  herself  beyond  reproach,  still 
had  such  an  illusion,  after  recovering  from  the  administration 
of  the  chloroform." 

"  Prosecution  of  a  Dentist. — ^At  the  Manchester  Assizes, 
before  Mr.  Justice  Day,  an  action  was  brought  against  Mr. 
James  Jackson,  a  dentist,  of  Burnley,  in  which  the  plaintiff, 
Mr.  Eobert  Jackson,  farmer,  sought  to  recover  damages  for 
the  alleged  seduction  of  his  daughter,  while  under  the  influence 
of  nitrous  oxide.  There  was.  also  a  cross-action  for  slander 
brought  against  the  plaintiff.     The  trial  occupied  nearly  three 


"  His  Lordship,  in  summing  up,  said  the  one  substantial  issue 
for  the  jury  was,  did  James  Jackson,  the  dentist,  or  did  he  not, 
administer  gas  or  some  narcotic  to  the  young  woman,  Margaret 
Ann  Jackson,  and  did  he,  while  she  was  under  the  influence 
of  some  anaesthetic,  criminally  assault  her?  That  was  the 
20 


458  ARTIFICIAL  AXiESTHESIA. 

question  they  had  to  determine,  and  it  was  a  question  of  the 
very  gravest  moment.  The  consequences  to  the  one  side,  or 
the  other,  must  necessarily  be  of  the  most  serious  character. 
The  cliarge  which  was  made  against  the  dentist,  was  one  of 
assault,  under  circumstances  of  the  most  aggravated  and  nefa- 
rious nature.  The  charge,  on  the  other  hand,  of  which  the 
woman  would  be  guilty,  if  she  had  made  a  false  accusation, 
was  one  of  the  most  wicked,  odious  and  vile,  that  could  be 
brought  by  one  human  being  against  another.  The  case  was 
one  of  a  most  extraordinary  character,  and  one  which,  he  was 
happy  to  think,  was  very  rarely  raised  in  a  court  of  justice. 
It  was  one  which  demanded  at  the  hands  of  the  jury,  as  he 
knew  it  would  most  assuredly  receive,  their  deepest  and  most 
anxious  attention,  so  that  to  the  utmost  of  their  ability  they 
might  do  justice  between  the  parties.  He  did  not  hesitate  to 
say  that  the  question  was  of  an  extremely  difficult  character, 
but  it  was  one  which  he  was  confident  the  jury  would,  using 
their  own  good  sense,  solve  to  their  thorough  satisfaction  ; 
and  if  they  did  solve  it  to  their  satisfaction,  it  should  be  satis- 
factory to  all  well-minded  people.  He  would  say  nothing 
about  damages,  because  it  was  unnecessary.  The  parties  prob- 
ably were  none  of  them  in  a  position  to  pay  damages.  That, 
however,  was  utterly  unimportant,  and  should  not  affect  the 
amount  of  damages.  It  was  unnecessary  for  him  to  say  a 
word  about  damages,  because  he  should  not  venture  to  put 
any  limit  upon  the  damages  which  they  might  award,  to  either 
one  side,  or  the  other. 

"  The  jury  retired  to  consult  on  the  case,  and  after  deliber- 
ating for  three  hours,  returned  to  court,  and  stated  that  there 
was  no  possibility  of  their  coming  to  an  agreement.  The  judge 
thereupon  discharged  them." 

Cliloroform— Its  Action  as  a  Poison. 

Chloroform  is  an  irritating  poison.  In  a  case  quoted  by 
Taylor,  an  individual  swallowed  four  ounces.  He  was  able 
to  walk  a  considerable  distance  after  taking  this  large  dose, 
but  subsequently  fell  into  a  state  of  coma.    The  pupils  were 


POISONING   FROM   CHLOROFORM.  459 

dilated,  the  breathing  was  stertorous,  ihe  skin  cold,  pulse 
imperceptible,  and  there  were  general  convulsions.  He  re- 
covered in  five  days.  {Medical,  Qazette,  vol.  47,  page  675.) 
A  second  case  reported,  swallowed  nearly  two  ounces  and 
recovered ;  and  a  third  swallo  wed  two  ounces,  but  he  died 
in  six  hours  afterwards.  In  this  case,  the  pupils  were  fully 
dilated,  the  breathing  was  stertorous,  and  the  skin  covered 
with  a  cold  perspiration.  On  inspection,  the  lungs  were 
found  much  engorged  with  blood,  and  there  were  some 
apoplectic  effusions  in  these  organs.  The  stomach  was 
slightly  inflamed  in  patches,  and  the  mucous  membrane  was 
softened.  {American  Journal  Medical  Sciences,  October,  1866, 
page  571.) 

A  physician  set.  57,  swallowed  three  ounces  of  chloro- 
form. He  immediately  began  to  stagger,  as  if  intoxicated. 
He  vomited,  and  sank  into  a  deep  stupor,  and  was  in  a 
state  of  complete  ansesthesia.  His  skin  was  pale  and  tolerably 
warm ;  the  muscles  were  relaxed,  the  breathing  short,  and  the 
action  of  the  heart  weak  and  intermittent.  In  about  fourteen 
hours  sensibility  returned.  Acute  gastritis  ensued,  with  rapid 
collapse,  and  proved  fatal  in  twenty-nine  hours  from  the  time 
the  chloroform  was  taken.  [American  Journal  Medical  Sci- 
ences, January,  1870,  page  276.) 

Treatment. — In  poisoning  from  liquid  chloroform,  the  stom- 
ach pump,  and  emetic  should  be  resorted  to.  If  evidence  of  sus- 
pension of  the  action  of  the  heart  (syncope)  exists,  there 
should  be  a  free  exposure  of  the  face  to  a  current  of  air,  com- 
pression of  the  chest  and  artificial  respiration,  warm  app'lica- 
tions  to  the  chest,  with  an  inversion  of  the  body,  active  friction, 
and  stimuli  externally,  and  by  the  rectum.  The  poles  of  a  gal- 
vanic battery  applied  to  the  chest  and  side  of  the  neck,  with 
sponges  dipped  in  hot  water,  should  be  used.  Solution  of 
ammonia  in  water,  has  been  found  useful,  when  injected  hypo- 
dermically,  and  strychnia  in  the  same  way,  to  act  upon  the 
respiration.  Aromatic  spirits  of  ammonia  must  be  given,  and 
great  care  taken  of  the  gastritis,  and  disturbance  of  the 
liver,  which  are  apt  to  follow  in  the  convalescence  of  the 
patient. 


460  ARTIFICIAL   ANAESTHESIA. 

Case  of  Poisoning  from  Chloroform  Taken  Inter- 
nally.*— "  In  December  I  was  attending  Louise  E.,  six  years 
of  age,  for  measles.  The  characteristic  symptoms  were  wanting, 
and  the  child  was  rapidly  returning  to  health.  As  she  seemed 
more  feverish  than  usual  ou  the  afternoon  of  the  sixth,  the 
mother  determined  to  give  the  patient  a  dessertspoonful  of  the 
fever  mixture  I  had  ordered  some  days  before.  By  mistake, 
she  gave  the  child  a  dessertspoonful  of  Squibb's  chloroform. 
No  sooner  had  she  done  so  than  the  odor  made  her  aware  of 
the  substitution.  Messengers  were  immediately  dispatched  for 
any  physician  that  could  be  found,  and  the  husband  started  for 
my  office.  Unfortunately  I  was  not  at  home.  Arriving  soon 
after,  however,  I  drove  quickly  towards  the  house.  On  the 
way  I  met  my  friend  Dr.  H.  H.  Barker,  who  had  been  to  see 
the  patient,  and  was  returning  to  his  office  for  his  galvanic 
battery.  Having  procured  it,  we  drove  hurriedly  to  the  house 
of  my  patient.  We  found  there  Drs.  Wolhaupter,  and  Adams, 
who  were  endeavoring  to  promote  respiration.  An  emetic  dose 
of  sulphate  of  zinc  had  been  given,  and  the  child  had  vomited 
freely.  She  had  been  placed  in  a  hot  mustard  bath,  and  they 
had  endeavored  to  make  her  swallow  several  teaspoonfuls  of 
whiskey. 

"  Despite  all  this,  however,  she  seemed  to  be  sinking  rapidly. 
Her  respiratory  efforts  were  very  feeble,  her  heart-beats  scarcely 
perceptible,  the  conjunctiva  was  not  responsive,  her  teeth  were 
clenched,  her  limbs  fell  listlessly  where  placed,  she  made  no 
movement,  uttered  no  sound,  the  loudest  cry  failed  to  elicit  a 
response,  she  was  cold  and  nearly  pulseless — in  a  word,  death 
seemed  imminent. 

"  Dr.  Barker  having  prepared  the  battery,  Gaiffe's,  one  pole 
was  applied  in  the  cervical  region  at  the  anterior  surface  of  the 
sterno-cleido-mastoideus,  the  other  was  drawn  along  the  course 
of  the  phrenic  nerve.  Every  muscle  of  the  chest  and  abdomen 
was  made  in  turn  to  feel  the  electric  current. 

"  For  five  minutes,  this  was  done,  without  any  perceptible 

*By  T.  E.  McArdle,  A.M.,  M.D.,  Assistant  Surgeon,  Children's  Hospital,  Wash- 
ington, D.  C. 


THE   CHLOEOFOEM   HABIT.  461 

change  in  the  child's  condition.  But  soon  her  pulse  began  to 
be  distinguishable  at  the  wrist,  her  respiratory  muscles  began 
to  act  emphatically,  her  breathing  could  be  discerned,  her  eye- 
lids closed  on  touching  the  conjunctiva,  she  sat  up  and 
threw  away  the  electrodes,  when  we  forced  them  into  both  her 
palms. 

"  Again,  though,  she  immediately  dropped  off  into  a  heavy 
slumber,  and  once  more  more  the  battery  had  to  be  applied. 
After  half  an  hour  of  constant  application,  she  was  sufficiently 
conscious  to  reply  to  her  mother's  questions.  We  then  desisted 
from  our  efforts,  prescribed  some  stimulant,  gave  cracked  ice, 
and  kept  the  patient  awake.  I  ordered  a  mustard  plaster  to  be 
placed  over  the  epigastrium,  which  was  done  during  the  night, 
whilst  she  was  asleep.  She  slept  well,  and  experienced  no 
untoward  symptoms  afterwards." 

The  Chloroform  Habit. 

Apropos  of  this  habit,  which  seems  to  be  on  the  increase  in 
this  country,  we  note  the  conclusion  of  an  article  on  the  sub- 
ject, by  Dr.  A.  G.  Browning  in  the  Med.  Record,  April  25th. 
He  says :  "  The  man  maudlin  drunk,  on  the  meanest  whiskey, 
however  revolting,  is  a  prince  compared  with  such !  For  he 
was  jolly  once ;  the  chloroform  drunkard  never ! 

"But  it  goes  further:  the  process  is  one  of  thorough  emascu- 
lation— death,  with  geometrical  precision,  to  every  function  ; 
somatic  death,  with  no  incidental  solemnities,  and  but  a  shadow 
for  final  sepulture.  Every  physiological  process,  without  ex- 
ception, goes  down  in  the  WTeck.  So  surely  is  this  so,  that 
were  I  commissioned  to  destroy  my  kind — to  sap  their  morals, 
dwarf  their  intellects,  wither  their  physique,  and  stop  repro- 
duction, the  habitual  use  of  chloroform,  as  I  have  known  it 
practiced,  would  leave  nothing  to  be  desired. 

"  I  know  whereof  I  speak ;  do  not  overdraw,  nor  can  I  think 
my  experience,  wholly  exceptional  upon  a  more  general  com- 
parison of  notes. 

"  In  this  rambling  communication,  I  have  aimed  at  nothing 
but  a  narration  of  facts — no  attempt  at  theory,  or  speculation. 
I  will  add  here,  that  in  nearly  every  instance,  the  chloroform 


462  ARTIFICIAL  ANAESTHESIA. 

habit  has  seemed  to  replace  the  appetite  for  drink.  I  mean 
that  the  craze  for  chloroform  has  developed,  in  nearly  every 
case,  in  individuals  who,  though  strictly  temperate  themselves, 
come  of  a  line  of  drinkers,  more  or  less  remote.  Is  this  a  mat- 
ter of  hereditary  descent? — another  evidence  that  the 'sins  of 
the  fathers  are  visited  upon  the  children,  even  to  the  third  and 
fourth  generation  ? '  Temperance  reformers  may  make  a 
note." 

Ungar  (5  Cent,  fur  Chir.)  reports,  as  a  result  of  his  investi- 
gation, pursued  since  1883,  that  the  inhalation  of  chloroform 
produces  fatty  degeneration  of  the  heart,  of  the  diaphragm, 
and  other  striated  muscles,  and  also  of  the  parenchyma  of  the 
liver,  and  kidneys.  He  is  of  the  opinion,  that  protracted  in- 
halation of  chloroform  vapor,  during  tedious  operations,  may 
thus  produce  a  state  of  weakness,  in  which  a  second  inhalation 
may  prove  fatal,  though  the  patient  apparently  tolerates  the  first 
inhalation,  without  dangerous  symptoms.*  For  this  reason,  he 
opposes  the  use  of  chloroform  in  normal  child-birth.  The 
Philadelphia  County  Medical  Society,  has  recently  recorded  its 
opinion  that  "  the  administration  of  ether  is  not  only  neces- 
sary and  proper  when  pain  is  to  be  implicated  upon  patients 
with  cardiac  lesions,  but  lessens  the  dangers  incident  to  opera- 
tions, provided  that  due  care  be  taken  during  the  administra- 
tion of  the  anaesthetic,  and  proper  regard  be  paid  to  its  after- 
effects." 

Use  of  Morphine  with  Chloroform. 

He  quotes  the  statement  of  Filchne,  that  when  chloroform 
or  ether  is  inhaled  by  dogs,  to  whom  morphine  has  been  pre- 
viously given,  Cheyne-Stokes  breathing  results. 

Hewitt  believes,  that  the  effect  of  morphine  may  frequently 
serve  to  enfeeble  respiration,  and  thus  to  bring  on  a  fatal 
result,  which  might  have  been  averted  if  morphine  had  not 
been  used. 

Mixed  Anaesthetics. 

The  various  mixtures  of  chloroform  with  ether  and  alcohol, 
were  used  as  means  of  escaping  the  danger  of  chloroform. 

*Snowder  Hewitt's  Anseathetizer  {British  Med.  Journal]. 


EEPORT   OF   CHLOROFORM   COMMITTEE.  463 

They  first  received  their  impulse,  from  the  report  of  the  Chloro- 
form Committee,  of  the  Medical  Chirurgical  Society,  of  London, 
who  declared  their  superiority  in  point  of  safety.  M.  Perrin, 
gives  an  account  of  the  first  death,  known  at  that  time  to  have 
taken  place  under  a  given  mixture  of  ether  and  chloroform, 
and  gives  the  credit  to  the  chloroform,  as  being  improperly  ad- 
ministered, and  Snow  says,  the  patient  died  of  hemorrhage ;  but 
our  reading  of  the  case,  carefully  reported  by  Dr.  R.  Crockett,* 
leaves  the  decided  impression  that  chloroform  arrested  the 
heart's  action,  inducing  vomiting,  and  caused  a  stoppage  of 
respiration.  The  following  is  an  abstract  of  the  important 
facts  in  the  case,  and  is  interesting  as  the  first  death  from  the 
mixture  : — "  A  sprightly  little  boy,  five  years  of  age,  was  brought 
to  the  doctor  to  have  a  fatty  tumor  removed  from  his  back. 
The  tumor,  commencing  at  a  point  at  its  inferior  termination, 
opposite  the  last  rib,  about  two  and  a  half  inches  to  the  right 
of  the  spinous  processes,  and  extending  obliquely  upwards, 
crossing  the  spine  seven  inches,  required  two  elliptical  inci- 
sions, nine  inches  long,  for  its  removal."  The  operation  was 
commenced  at  9.30  a.m.,  April  4th,  and  the  dissection  was  rap- 
idly executed,  stopping  to  ligate  a  large  artery,  that  was  early 
divided;  the  remaining  arteries  were  compressed  as  they  were 
divided.  The  tumor  was  quickly  removed,  and  a  ligature  ap- 
plied to  the  last  artery,  being  the  sixth  in  number.  While 
sponging  the  wound,  the  boy  began  to  vomit,  and  on  exam- 
ining the  wrist,  he  was  found  to  be  pulseless.  Dr.  K.,  who  had 
charge  of  the  anaesthetic  and  pulse,  replied  that "  the  pulse  had 
never  given  way  until  he  began  to  vomit."  He  ejected  a  small 
portion  of  the  contents  of  the  stomach.  He  was  immediately 
placed  in  the  "prone  position,"  as  recommended  by  Dr.  Mar- 
shall Hall ;  the  finger  was  introduced  into  the  mouth  to  be  cer- 
tain that  the  tongue  had  not  fallen  back  so  as  to  obstruct  the 
glottis,  or  the  entrance  of  air  into  the  wind-pipe,  and  the  ex- 
tremities were  rubbed  with  aqua  ammonia.  The  patient  died, 
three  or  four  minutes  from  the  commencement  of  the  vomiting. 
"He  lost  probably  four  ounces  of  blood,  certainly  not  exceed- 
ing six."     There  was  no  post-mortem  examination. 

*  Am.  Jour.  Med.  ScL,  July,  1857,  pp.  2S4-5. 


464  ARTIFICIAL   ANESTHESIA. 

The  anaesthetic  used  was  a  mixture  of  washed  ether,  four 
parts,  and  one  of  chloroform,  obtained  from  the  late  Frederick 
Brown,  of  Philadelphia,  whose  character  is  a  sufficient  guaran- 
tee, that  they  were  pure.  Every  preparation  for  the  operation 
having  been  made,  the  administration  of  the  ana3sthetic  was 
commenced  by  Dr.  Crockett,  observing  all  the  precautions  so 
fully  recommended  by  Erichsen,  p.  78,  of  his  "  Operative  Sur- 
gery." As  soon  as  antesthesia  was  induced,  the  sponge  was 
confided  to  Dr.  Kincannon,  who  held  his  finger  all  the  while 
on  the  patient's  pulse.  The  doctor  concludes,  "I  have  lately 
employed  this  anaesthetic  freely,  formerly  having  used  ether 
alone.  As  yet  I  have  not  seen  a  case  of  death  reported  from  ether, 
or  this  mixture  of  it  with  chloroform,  that  I  can  now  recollect. 
Are  there  any  such  reported?  I  fear  all  the  deaths  from  anaes- 
thesia are  not  reported."  Five  deaths  from  the  use  of  this 
mixture  have  been  published,  two  having  occurred  very  re- 
cently. 

The  chief  object  of  these  anaesthetic  mixtures,  is,  the  avoid- 
ance of  the  danger  from  shock,  or  from  the  depressing  influence 
upon  the  heart-action,  which  chloroform  most  certainly  exerts, 
and  which  ether  and  alcohol  prevent.  The  committee  before 
referred  to  proposed  the  following  mixtures  : — 

A.  Alcohol 1  Part 

Chloroform 2  " 

Ether 3  " 

B.  Chloroform 1  " 

Ether 4  " 

C.  Chloroform 1  " 

Ether 2  " 

Dr.  Sansora's  mixture*  is  equal  parts  by  measure  of  chlo- 
roform, and  absolute  alcohol.  The  introduction  of  alcohol, 
which  plays  an  important  part  in  the  mixture,  was,  according 
to  the  doctor,  due  to  Dr.  Harley.  The  committee  says,  it  is  by 
"the  uniform  blending  of  the  ether  and  chloroform,  when  com- 
bined with  alcohol,  and  probably  the  more  equable  escape  of 

*  Cliloroform  :  Its  Action  and  Administration.  By  Arthur  Sansom,  M.B.,  London. 


OBJECTIONS    TO    ANAESTHETIC   MIXTUHES.         465 

the  constituents  in  vapor."  The  chloroform  is  the  potent 
agent,  and  the  others  chiefly  coadjutors,  vehicles  and  diluents 
of  the  chloroform. 

Dr.  Sansom  gives  the  following  testimony,  as  to  the  stimu- 
lating effects  of  alcohol,  in  counteracting  the  depressing  influ- 
ence of  chloroform  :  "  In  my  own  experiments,  I  have  found 
that  alcohol  has  had  the  greatest  effect,  in  sustaining  the  heart- 
action  during  the  influence  of  the  chloroform.  I  can  particu- 
larly recollect  one  instance,  in  which  alcohol  was  administered 
in  vapor  to  a  frog,  after  it  was  impossible  to  cau^e  death  by  any 
Btreagth  of  chloroform  vapor."  In  recommending  this  mixture 
before  the  Obstetrical  Society  of  London,  Dr.  Sansom  went  one 
step  farther,  aad  stated  that  this  mixture  gives  off  a  proportion 
of  chloroform  vapor  in  a  given  time  almost  exactly  half  of  that 
which  is  given  off  by  chloroform  pure  and  simple.  The  result 
is  not  confirmed  by  any  experiment  of  his  published. 

What  are  the  objections  to  ancesthetic  mixtures  f 

1.  The  length  of  time  required  for  the  production  of  com- 
plete ansesthesia.  2.  The  probability  of  entire  sensibility  not 
being  abolished.  3.  The  unequal  rate  of  evaporation  or  vapor- 
ization of  the  fluids. 

There  is  not  any  doubt,  but  that  the  process  is  slower  and  at- 
tended with  more  excitement  by  the  mixed  fluids,  than  by  chlo- 
roform alone.  The  second  objection  cannot  be  sustained.  The 
third  is  the  "  element  of  danger.''  It  was  first  advanced  by 
Snow.  He  says  :  "  When  ether  is  combined  with  chloroform, 
the  result  is  a  combination  of  the  undesirable  qualities  of  both 
agents,  without  any  compensating  advantage,"  and  the  danger 
is  because  the  operator,  toward  the  end  of  the  peocess,  may  be 
giving  a  pure  chlorofoi'm,  when  he  thinks  he  is  giving  the 
w^eaker  mixture  of  vapors.  Dr.  Ellis,  endeavored  to  prove  this, 
and  states  :  "Out  of  the  six  or  seven  minutes  occupied  by  the 
evaporation  of  the  half  drachm  of  fluid,  the  first  was  occupied 
chiefly  by  the  ether,  the  next  three  by  the  chloroform,  with  a 
little  alcohol,  and  the  last  by  the  alcohol  alone.  In  an  inhaler, 
the  patient  would  have  breathed,  for  one-fifth  of  the  time, 
chiefly  the  vapor  of  ether,  for  the  next  three-fifths,  that  of  chlo- 
roform, with  a  little  alcohol,  and  at  last,  only  the  vapor  of  a 

20* 


466  ARTIFJCIAL  ANESTHESIA. 

minute  quantity  of  alcohol."  These  results,  are  not  stated  aa 
obtained  by  actual  experiments,  and  they  depend,  first,  upon  the 
purity  of  the  ageuts  employed  ;  second,  upon  the  boiling-point, 
which  has  a  great  influence  upon  the  results,  for  the  more  vol- 
atile the  fluid,  the  greater  will  be  the  variation.  We  here  give 
the  boiling-point   of  the  most  important  anajsthetics. 

The  temperature  which  is  constant  for  the  same  substance, 
under  the  same  atmospheric  pressure,  is  called  the  boiling- 
point. 

The  following  are  the  agents  employed  as  anaesthetics  in  the 
form  of  vapor,  the  boiling  points  being  given  for  the  mean 
pressure  of  760  millimetres : 

Protoxide  of  nitrogen — 88° 

Carbonic  acid — 78° 

Chloride  of  Ethyl  V.  pure  ether -)-ll° 

Ether 35° 

Chloroform 63° 

Alcohol 78° 

Oil  of  turpentine .    157° 

A  difference  of  pressure  of  0.25  centimeter,  will  cause  a  dif- 
ference in  the  boiling  of  water  one-tenth  of  a  degree.  The 
boiling-point  is  also  influenced  by  dis-iolving  in  a  fluid  a  sub- 
stance more  volatile  than  itself,  (as  ether  and  chloroform) ;  it 
increa-es  the  boiling-point,  in  proportion  to  the  amount  dis- 
solved. The  temperature  of  the  atmosphere  has  a  powerful  in- 
fluence on  these  volatile  agents,  as  it  is  a  well-known  chemical 
fact,  th'it  the  saturability  of  the  air,  increases  vastly  with  the  in- 
crease of  temjierature,  and  the  capacity  of  the  air  for  aqueous 
vapor,  is  doubled  with  each  27°  of  temperature  Fahrenheit. 
Sulphuric  ether  at  60°  F.,  and  thirty  inches  of  the  barometer 
expands  two  parts  of  the  air  into  three,  and  forms,  therefore,  at 
that  temperature,  and  pressure,  one-third  of  the  air  inhaled  into 
the  lungs  of  a  patient.  Under  the  same  circumstances,  chloro- 
form expands  fourteen  parts  of  air  into  fifteen,  and  conse- 
quently the  vapor  of  chloroform  constitutes  one-fifteenth  part 
of  the  air  inhaled. 

The  following  experiments  were  made  October  30th,  1878,  so 


EVAPORATION  OF   ANESTHETIC   AGENTS.        467 

as  to  determine  the  time  required  for  eacli  of  the  agents  to 
evaporate  on  a  given  surface  of  tissue-paper,  suspended  in  the 
air  at  a  temperature  of  70°  F.,  one  drop  of  each  being  carefully- 
measured  by  the  same  dropping  machine.  The  time  was  accu- 
rately kept  by  Dr.  C.  S.  Turnbull,  son  of  the  writer,  and  the 
results  served  to  confirm  the  rough  experiments  made  before 
the  Dental  Convention  at  Washington,  D.  C,  on  October  10th, 
1878,  and  proved  the  facts  stated  in  the  author's  first  edition  of 
this  work.  We  have  always  found  that  when  such  a  mixture  was 
poured  upon  the  inhaler,  the  most  volatile  spirit  would  rise 
first,  then  the  next,  and  so  on,  leaving  the  least  easily  evapor- 
ated upon  the  inhaler.  Another  important  fact  was  proven, 
and  which  was  before  referred  to,  that  the  alcohol  employed  in 
the  mixtures  with  chloroform  in  England,  also  the  ethers  made 
from  such  alcohols,  are  much  inferior  to  those  made  in  this 
country  from  grain,  not  from  wood,  potatoes  or  other  agents. 
These  latter  are  slow  in  evaporation,  and  are  mixtures  them- 
selves containing  a  large  amount  of  carbonaceous  products. 

The  following  are  the  results  obtained  after  numerous  ex- 
periments with  as  many  of  the  agents  employed  in  the  various 
mixtures,  and  obtained  from  the  reliable  establishments  of 
Powers  &  Weightman,  Bullock  &  Crenshaw,  Wyeth  &  Bro., 
and  J.  P.  Eemington : 

Alcohol,  absolute  95°  (W.  &  Bro.) 1  min.  24  seconds. 

Alcohol,  common  (W.  &  Bro.)   . 10  "  00 

Chloroform  (P.  &    W.) 00  "  24 

Ether  (Squibb's) 00  "  12 

Ether,  common,  0.750  (P.  &  W.) 00  "  24 

Ether,  Hydrobromic  (R.) 00  '«  12 

Methylic  alcohol  (B.  &  C.) 1  "  00 

Potato  spirit*  (B.  &C.)    ...........  12  •'  00 

Temperature,  70°  F. 
Barometer,  30.08.     Time,  2  p.m. 

Besides  the  danger  from  inhaling  the  ether  pure  and  sim- 
ple, ther^  is  another  to  be  prevented — that  is,  to  get  rid  of 
the  watery  vapor,  from  the  mixture  and  also  from  the  lungs  of 

*  Passed  through  charcoal  by  W.  &  Bro. 


468  AETIFICIAL   ANAESTHESIA. 

the  patient,  which  collects  on  the  sponge.  If  the  napkin  or  in- 
haler gets  close  to  the  patient's  mouth,  and  nose,  it  will  most 
effectually  prevent  air  from  reaching  the  lungs.  How  is  this 
to  be  prevented?  By  squeezing  out  the  sponge,  napkin,  lint> 
or  if  an  inhaler  is  employed  that  cannot  thus  be  treated,  cast- 
ing it  aside,  and  taking  a  clean  napkin,  with  as  much  starch  in 
it  as  possible,  so  as  to  keep  it  in  shape.  It  may  again  be  in- 
quired, which  is  the  best  mixture  to  employ  in  ordinary  surgi- 
cal operations  when  it  is  absolutely  necessary  to  employ  such 
mixtures.  The  mixture  C,  in  midwifery.  Mixture  A,  or,  as  it 
is  familiarly  known,  A.-C.-E.  or  "  ace-of-spades  mixture,"  the 
most  agreeable  of  all.  In  the  operation  for  ovariotomy,  we  pre- 
fer the  C  mixture,  as  also  advised  by  the  late  Dr.  Washington 
Atlee;  the  volumes  of  the  two  agents  are  so  different  that  they 
ought  to  be  mixed  by  weight,  not  by  measure,  else  chloroform 
■will  be  much  in  excess,  as  it  is  a  little  over  twice  the  weight  of 
ether.  In  employing  alcohol,  it  should  be  as  near  to  absolute, 
as  possible,  and  free  from  color,  smell,  or  taste.  The  ether 
should  be  almost  anhydrous,  pure,  lull  strength,  and  well 
washed. 

Dr.  Atlee,  was  of  the  opinion  that  there  is  a  chemical  union 
of  the  ether,  and  chloroform;  and  Professor  Maisch, of  this  city, 
found  that,  if  this  mixture  was  exposed  to  the  light,  a  change 
took  place  which  rendered  the  mixture  not  fit  for  the  purposes 
of  inhalation;  it  therefore  should  be  kept  from  the  light,  and 
mixed  just  before  being  employed. 

Perfectly  dry  chloroform  decomposes  but  slowly,  even  in  di- 
rect sunlight;  but  the  presence  of  water,  which  always  exists  in 
alcohol,  and  ether,  and  the  action  of  light  at  the  same  time, 
causes  chloroform  to  decompose  into  formic  and  hydrochloric 
acids.   CHCl3+2H,0=CH,0,+3  HCL. 

We  have  had  charge  of  the  anaesthetic  mixture  (one  part  by 
measure  of  chloroform,  and  two  of  washed  sulphuric  ether),  in 
an  operation  by  Dr.  Washington  L.  Atlee,  during  the  success- 
ful removal  of  an  ovarian  tumor,  weighing  forty  pounds,  and 
have  also  assisted  him  in  three  cases,  in  which  others  gave  this 
same  mixture,  with  good  results,  and  with  no  apparent  risk  to 
the  safety  of  the  patients. 


DR.  w.  atlee's  mixture.  469 

Dr.  Atlee  always  administers  the  anaesthetic,  after  the  patient 
is  upon  the  operating  table,  and  one  individual  has  charge  of, 
and  is  responsible  for,  it.  In  his  three  hundred  ovariotomies, 
he  informed  me,  he  had  never  lost  a  patient  by  the  anaes- 
thetic. 

The  mixture  is  given,  in  almost  every  instance,  by  means 
of  the  starched  towel. 

The  following  experiments  were  made,  to  determine  the 
action  of  ether  and  chloroform  when  mixed:  When  ether 
and  chloroform  are  mixed,  there  is  an  elevation  of  temper- 
ature, and  the  greatest  heat  is  produced  when  the  mix- 
ture is  made  in  equivalent  proportions ;  that  is,  by  weight, 
about  nine  and  one-quarter  parts  of  ether,  to  thirteen  and  one- 
quarter  parts  of  chloroform.  As  the  chloroform  is  more  than 
twice  as  heavy  as  ether,  the  volumes  would  be  about  one  and 
four-tenths  chloroform,  to  two  of  ether.  But  little  contraction 
in  volume  takes  place,  and  it  may  be  considered  that  molec- 
ular combination  takes  place,  between  the  chloroform  and 
ether.  The  mixture  begins  to  boil  at  fifty  to  fifty-one  degrees 
C,  and  may  be  separated  into  its  constituents  by  fractional 
distillation  ;  but  when  allowed  to  evaporate  spontaneously,  as 
when  used  as  an  anaesthetic,  both  liquids  pass  into  vapor  sim- 
ultaneously. 

Whatever  mixture  is  employed,  nothing  will  obviate  the 
necessity  of  care  in  the  administration,  and  above  all,  do  not 
give  more  of  the  agent  than  is  absolutely  necessary  to  keep 
the  patient  free  from  pain;  not  one  drop  more,  for,  like  all  po- 
tent medicines  which  we  employ,  an  excessive  dose  is  sure  to 
kill,  and  unless  we  have  before  gauged  the  patient's  powers,  let 
caution  be  our  guide  in  the  administration  of  so  powerful  an 
ansesthetic.  In  our  anxiety  to  see  the  various  steps  of  an  op- 
eration, we  must  not  saturate  the  sponge  or  lean  over  the  pa- 
tient, and  by  accident  suffocate  him.  It  is,  unfortunately,  too 
much  the  practice  to  intrust  the  inhaling  apparatus  to  some  in- 
experienced hand,  who,  perhaps,  never  before  administered  an 
ansesthetic,  and  even  in  some  hospitals,  to  the  youngest  assist- 
ant surgeon,  or  dresser.  It  has  been  well  observed  by  Perrin  : 
"  We  believe  we  shall  render  a  veritable  service,  if  we  popular- 


470  ARTIFICIAL   ANESTHESIA. 

ize  the  idea,  that  an cesthesia  should  be  observed,  and  studied  at 
the  liospital,  with  as  much  care,  as  every  other  subject  of  prac- 
tical medicine."  Sansom  also  says,  "  The  administrator  should 
be  experienced  ;  several  hospital  committees  have  acted  wisely 
in  appointing  a  chloroformist,  a  mea^iure  which  is  not  of  less 
value  to  the  operating  surgeon,  than  it  is  to  the  benefit  of  the 
patient.  One  who  administers  chloroform  in  any  case,  should 
confine  himself  exclusively  to  the  task  he  has  undertaken,  and 
should  constantly  mark  the  symptoms."  What  are  the  symp- 
toms of  danger?  The  failure  of  the  pulse,  irregularity  of  the 
respiration,  and  the  blanched  countenance,  and,  as  beautifully 
expressed  by  an  old  writer  in  reference  to  successful  adminis- 
tration of  anaesthetics  :  "  Proceed  steadily  but  cautiously  to  the 
end  in  view.  He  who  makes  haste  slowly,  and  with  a  boldness 
tempered  by  wisdom,  carries  his  patient  down  into  the  dark 
valley  which  borders  on  death,  drowns  human  agonies  in  the 
water  of  Lethe,  and  triumphs  in  the  crowning  glory  of  his 
art." 

Mixed.  Anpestliesia  in  Oplitlialniic  Surgery. 

This  method  of  producing  anassthesia,  by  the  combined  ad- 
ministration of  narcotics,  and  ansesthetics,  was  originally  rec- 
ommended by  "Bernard  of  Paris,"  who  founded  it  upon  experi- 
ments on  animals,  and  his  results  were  confirmed  to  a  certain 
extent  on  man;  but  it  has  never  been  successfully  employed 
or  recommended  either  in  England,  or  this  country,  as  morphia 
will  frequently  produce  vomiting  or  depressing  symptoms  in 
certain  individuals.  Mr.  Ernest  Hart,  in  some  recent  notes 
on  "Medical  Paris,"  states,  that  for  the  last  ten  years,  the 
method  has  been  used  at  the  Sorbonne,  in  anassthetizing  ani- 
mals for  experimentation,  and  without  a  single  accident, 
whereas  with  the  ordinary  method,  the  mortality  from  chloro- 
form, was  one  animal  in  three,  and  sometimes  even  greater. 

The  mixed  method,  as  generally  used  in  the  human  being, 
consists  in  injecting  hypodermatically  from  |  to  |  gr.  of  mor- 
phia and  ^^2  to  -gs  gr.  of  atropia,  from  fifteen  to  twenty-five 
minutes,  before  the  inhalation  of  the  anaesthetic,  just  long 
enough  for  the  effect  of  the  narcotic  to  be  fully  feit  by  the 
nervous  centres. 


MIXED   ANAESTHETICS.  471 

"The  selection  of  the  ancesthetic  agent  in  ophthalmic  sur- 
gery, is  a  matter  of  considerable  importance.*  But  for  its  lia- 
bility to  occasional  death,  there  is  nothing  which  combines  so 
many  advantages  as  pure  chloroform;  but  this  liability  is 
enough  to  neutralize  them  all.  Chloroform  kills,  in  round 
numbers,  about  one  in  every  three  thousand,  of  those  to  whom 
it  is  administered,  and  there  ought  to  be  no  deaths  in  ophthal- 
mic surgery.  If  experience  has  made  anything  certain,  I 
think  it  is,  that  the  fatal  accidents  from  chloroform  have  oc- 
curred, in  the  very  cases  in  which  there  was  no  reason  to  an- 
ticipate them.  I  sometimes  use  it  when  I  am  short-handed, 
and  when  the  administrator  is  comparatively  unskilled  in  the 
use  of  anaesthetics,  because  I  think  it  is  then  as  safe  as  any 
other,  and  is  more  easy  of  administration,  and  more  likely  to 
be  eflFectual  than  any  other.  Excepting  in  such  conditions? 
and  in  the  case  of  young  children,  in  whom  the  danger  to 
life  from  its  effects  seems  to  be  almost  infinitesimally  small, 
I  think  it  ought  to  be  banished  from  surgery.  Pure  ether 
is  an  admirable  and  very  safe  anaesthetic;  but  it  requires  a 
boldness  and  freedom  of  administration  which  are  only  at- 
tained by  practice,  and,  if  imperfectly  given,  it  is  utterly 
inefficient  for  the  purposes  of  the  ophthalmic  surgeon.  More- 
over, it  is  apt,  especially  if  tardily  and  ineffectually  admin- 
istered, to  produce  a  free  secretion  of  bronchial  mucus,  which 
occasions  troublesome,  and  unrestrained  coughing,  and  some- 
times leads  to  sickness.  When  nitrous  oxide  gas  is  admin- 
istered as  a  prelude  to  ether,  the  secretion  of  mucus  is  less 
likely  to  be  troublesome;  but  a  great  amount  of  venous  con- 
gestion is  always  produced,  and  the  tissues  become  so  gorged 
that  every  incision  bleeds  freely.  In  the  performance  of  iri- 
dectomy, under  gas  and  ether,  we  not  only  have  an  unusual 
amount  of  bleeding  from  the  conjunctiva,  or  from  the  vessels 
of  Schlemm's  canal,  if  these  should  be  divided,  but  we  also 
have  a  large  effusion  of  dark,  and  unoxygenized  blood  into 
the  anterior  chamber,  from  the  cut  edges  of  the  iris,  and  this 
blood,  as  already  incidentally  mentioned,  is  prone  to  act  as  a 

*  Dr.  Carter,  London. 


472  ARTIFICIAL   ANESTHESIA. 

foreign  body,  and  to  excite  troublesome,  and  possibly  very  inju- 
rious iritis. 

"  Judging  from  Dr.  Carter's  opportunities  of  observation,  he  is 
inclined  to  believe  that  the  best  anaesthetic,  for  general  use  in 
ophthalmic  surgery,  is  the  mixture  which  is  commonly  known 
as  A.-C.-E.,  and  which  contains  one  part  by  measure  of  absolute 
alcohol,  two  of  chloroform,  and  three  of  ether.  A  mixture  of 
ether  and  chloroform  was  long  ago  suggested  by  very  obvious 
considerations;  but  it  was  not  found  to  succeed  well  in  prac- 
tice. It  was  merely  a  mixture;  and,  as  its  ingredients  were  of 
different  degrees  of  volatility,  they  evaporated  unequally,  and 
left  the  administrator  in  a  state  of  uncertaintj',  with  regard  to 
the  proportion  of  each,  which  might  be  left  in  his  inhaler  at 
any  given  time.  The  addition  of  alcohol,  provides  a  solvent 
for  the  other  two,  and  they  evaporate  together.  The  mixture 
should  be  administered  freely,  from  a  flannel  or  felt  cone,  and 
the  desired  efl'ect  should  be  produced  as  rapidly  as  possible. 
To  prolong  the  administration  of  an  anaesthetic,  of  whatever 
nature,  to  give  small  doses  timidly,  with  frequent  admissions 
of  air  between  them,  is,  I  believe,  the  most  certain  method  of 
producing  disaster  from  its  imperfect  operation.  By  disaster, 
I  do  not  mean  death,  but  incomplete  anaesthesia,  prolonged 
struggling,  muscular  spasm,  and  probably  eventual  sickness. 
The  cases  which  do  best  are  those  in  which  the  effect  is  rap- 
idly produced,  and  in  which  it  is  as  rapidly  recovered  from. 
It  would  be  foreign  to  my  subject,  and  beyond  the  limits  of 
my  time,  to  attempt  to  describe  the  precautions  with  which 
the  use  of  every  anaesthetic  should  be  surrounded  ;  but  I  may 
add  that  one  advantage  of  the  A.-C.-E.,  is  the  ease  with  which 
the  mixture  can  be  replaced  by  pure  ether,  in  cases  which 
seem  to  call  for  such  a  substitution.  When  this  substitution 
is  made,  moreover,  the  patient  being  already  narcotized  by  the 
A.-C.-E.,  the  pure  ether  has  little  tendency  to  produce  the  ex- 
cessive bronchial  secretion,  which  constitutes  one  of  the  difficul- 
ties of  its  employment,  from  the  first.  I  need  only  add  that, 
more  especially  in  cataract  operations,  the  ophthalmic  surgeon 
who  cares  for  the  welfare  of  his  patients,  or  for  his  own  repu- 
tation, will  not  lightly  commit  the  anaesthetic  to  strange  or 


AUEAL  DISEASES   FEOM   ANESTHETICS.  473 

unskilled  hands,  but  will  insist  upon  obtaining  the  aid  of  an 
administrator  of  skill  and  experience,  who  knows  the  special 
requirements  of  eye  work,  and  who  is  capable  of  relieving  the 
operator  from  the  duty  of  thinking  at  all  about  the  anaesthetic 
or  its  etfects.  The  administrator  should  then  assume  entire 
responsibility  for  his  share  of  the  proceedings,  and  the  surgeon 
should  await  his  permission  to  commence."*  The  fortunate 
discovery  of  the  local  anaesthetic  properties  of  the  hydrochlo- 
rate  of  cocaine,  has  done  away  with  the  use  of  such  powerful 
and  dangerous  anaesthetics  as  chloroform  and  ether  in  opera- 
tions on  the  eye. 

Tlie  Inlialation  of  Chloroform  and  Ether,  a  Cause 
of  Aural  Disease. 

Several  cases  of  deafness  are  reported  by  Dr.  Charles  E. 
Hackly,  of  New  York,  as  having  followed  the  inhalation  of 
chloroform  for  complete  narcosis,  for  surgical  operations. 

Dr.  D.  B.  St.  John  Roosa,  of  New  York,  has  also  published 
that  several  cases  of  tinnitus  aurium,  and  loss  of  hearing,  have 
come  under  his  observation,  which  were  said  to  have  been 
caused  by  the  inhalation  of  ether  for  the  purposes  of  anaesthesia. 
No  such  results  have  followed  in  our  use  of  anaesthetics. 

Brief  Extract  of  Experiments  with  a  Mixture  of 

Ether  and  Bromide  of  Ethyl  and  Chloroform, 

Performed  by  Drs.  Keichert,  Turnhull  and 

Thomas,  May  6,  1885. 

Experiments  were  performed  first  upon  a  rabbit,  then  upon 
a  dog.  In  the  first  instance  a  mixture  of  ether  and  bromide  of 
ethyl,  (  §ij  to  Oj)  was  applied,  and  the  animal  prepared  by  in- 
serting a  tube,  to  which  a  pulse  indicator  was  attached,  into  the 
carotid  artery,  thereby  showing  the  regular  action  of  the  heart. 
The  trachea  was  opened,  and  a  tube  applied. 

The  nasal  branch  of  the  fifth  pair  of  nerves  was  irritated, 
and  inhibition  of  the  heart's  action  was  immediately  shown, 
and  when  repeated,  cessation  was  almost  produced.     The  ani- 

* "  Modern  Operations  for  Cataract,"  E.  B.  Carter,  Medical  Times  and  Gazette 
London,  Feb.  9,  1884. 


474  ARTIFICIAL   ANAESTHESIA. 

mal  was  allowed  to  recover,  after  which,  it  was  proposed  to  apply 
chloroform,  and  repeat  the  test ;  but  almost  simultaneously  with 
the  application  of  the  chloroform,  the  heart's  action  ceased  en- 
tirely, showing  the  dangerous  character  of  that  agent  as  an  an- 
esthetic. 

The  post-mortem  showed  the  lungs  tobe  in  a  normal  condition, 
as  were  also  all  the  organs,  except  the  liver,  which  was  badly 
tuberculous,  a  condition  frequently  found  in  the  rabbit.  A 
perceptible  heart-motion  continued  for  some  time  after  death, 
but  with  insufficient  force  to  propel  the  blood,  the  indicator 
remaining  perfectly  quiet. 

In  the  second  instance,  ether  was  applied  to  the  dog  with 
similar  preparation  as  the  rabbit,  and  with  like  result,  after 
which  he  was  injected  with  chloral,  and  a  current  of  electricity 
was  applied  to  the  laryngeal  branch  of  the  pneumogastric 
nerve.  The  effect  upon  the  heart  was  instantaneous,  to  such  an 
extent,  as  to  cause  complete  suspension  of  the  pulsation.  The 
result  was  the  same,  when  the  current  was  applied  directly  to 
the  pneumogastric,  the  continuance  of  which  must  have  pro- 
duced death. 

Anaestliesia  by  Cliloroform  and  Oxygen. 

Dr.  Kreutzmann,  of  San  Francisco,  employed  not  the  pure 
chloroform,  but  Billroth's  mixture  (three  parts  of  ether  to  one 
of  chloroform)  in  conjunction  with  oxygen.  The  discoverer  of 
this  method  was  Dr.  Neudorfer,  of  Vienna,  who  claims,  on 
theoretical  grounds,  that  its  employment  is  entirely  without 
danger.  This  cannot  be  so,  for  no  mixture  containing  chloro- 
form is  absolutely  safe. — Pacific  Med.  and  Surg.  Jour.,  August, 
1887. 

Einploymeiit  of  Chloroform  in  Labor. 

It  should  never  be  pushed  to  complete  insensibility,  but  the 
patient  should  be  held  in  a  state  of  semi-ansesthesia,  so  as  to 
produce  a  diminution  of  the  suffering. 

The  general  rule  is,  never  to  administer  chloroform  except 
during  the  period  of  expulsion. 

Experience  has  shown,  that  anaesthetics  do  not  arrest  the  con- 


ANiESTHETICS   IN   LABOR.  475 

tractions  of  tlie  uterus  or  abdominal  muscles,  but  that  tbey 
weaken  the  natural  resistance  of  the  perineal  muscles. 

In  lessening  the  suffering,  anaesthetics  render  a  great  service 
to  those  women  who  dread  the  pain  ;  they  diminish  the  chances 
of  the  nervous  crises,  which  are  caused  during  labor,  by  the  ex- 
cess of  suffering ;  they  make  the  recovery  more  rapid. 

They  are  especially  useful,  to  calm  the  great  agitation  and 
cerebral  excitement,  which  labor  often  produces  in  every  ner- 
vous woman. 

Their  employment  is  indicated  in  natural  cases,  until  the 
pains  are  suspended,  or  retarded,  by  the  suffering  caused  by  mal- 
adies, occurring  previous  to,  or  during  labor,  and  in  those  cases, 
where  irregular,  and  partial  contractions,  occasion  internal  and 
sometimes  continuous  pain,  without  causing  progress  of  the 
labor.  In  a  natural  labor,  chloroform  should  never  be  used 
without  the  consent  of  the  woman,  and  her  family. 

The  experience  of  British  practitioners,  is  generally  under- 
stood to  have  disposed  them  to  regard  the  use  of  chloroform  in 
labor,  as  a  proceeding  of  the  highest  utility  and  moment ;  and, 
according  to  the  mode  and  limits  of  the  inhalation  practiced  in 
the  circumstances,  practically  free  from  danger.  Yet  in  Ire- 
land, they  differ  very  much  in  this  matter,  as  may  be  seen  from 
Dr.  Johns'  observations.  Dr.  William  T.  Lusk,  of  New  York, 
dvpells  on  the  necessity  of  "Caution  in  the  Use  of  Chloroform 
during  Labor."  He  expresses  his  belief  that  "  not  a  small 
number  of  persons  have  quietly  abandoned  chloroform  as  a 
pain-stilling  agent,  because  some  incident  in  their  practice  has 
led  them  to  suspect,  that  in  spite  of  statistics,  it  possesses  dan- 
gerous properties."  The  author  divides  his  subject  according 
to  the  following  heads  : 

1.  Deep  ancesthesia,  carried  to  fhe  point  of  complete  abolition 
of  consciousness,  in  some  cases,  weakens  uterine  action,  and  some- 
times suspends  it  altogether. 

2.  Chloroform,  even  given  in  the  usual  obstetrical  fashion, 
namely,  in  small  doses,  during  the  pains  only,  and  after  the  com- 
mencement of  the  second  stage,  may,  in  exceptional  cases,  so  far 
weaken  uterine  action,  as  to  create  the  necessity  for  resorting  to 
ergot,  or  forceps. 


476  AETIFICIAL  ANAESTHESIA. 

3.  Patients  in  labor,  do  not  enjoy  any  absolute  immunity  from 
the  pernicious  effects  of  chloroform. 

4.  Chloroform  should  not  be  given  in  the  third  stage  of  labor. 
The  relative  safety  of  chloroform  ceases  with  the  birth  of  the  child. 

5.  The  more  remote  influence  of  large  doses  of  chloroform,  dur- 
ing labor,  upon  the  puerperal  state,  is  a  subject  that  calls  for  fur- 
ther investigation  and  inquiry. 

Dr.  Playfair  thinks,  that  chloroform  inhalation  is  too  indis- 
criminately used,  and  says,  that  he  has  observed  the  pains 
alter,  and  become  less  effectual.  After  chloroformization, 
and  when  it  is  prolonged,  he  thinks  it  favors  post-partum  hem- 
orrhage. 

In  a  recent  case  which  came  under  the  writer's  notice,  where 
three  pints  of  chloi'oform  had  been  employed  in  tedious  labor, 
there  was  great  retardation ;  and  ultimately,  when  the  forceps 
were  applied,  the  infant  was  so  narcotized  from  the  effects-  of 
the  chloroform,  that  every  means  employed  to  restore  it  failed. 

Dr.  Colling  reported  in  the  Boston  Medical  and  Surgical  Jour- 
nal of  January  11th,  1876,  a  case  of  death  by  chloroform  in 
parturition.  The  patient  was  a  primipara,  aged  twenty-two. 
The  labor  was  proceeding  well,  and  the  head  was  apparently 
on  the  point  of  emerging,  when  the  patient  had  a  slight  con- 
vulsion. Chloroform  was  administered,  and  the  pains  returned  ; 
and,  still  later,  the  administration  was  repeated.  The  head  was 
gotten  away,  and  the  uterus  was  contracting  well,  when  a  tremor 
occurred,  the  pulse  ceased,  and  the  patient  was  dead. 

Practical  Observations  on  the  Injurious  Effects  of 
Cliloroforni  Inhalation  during-  Labor.* 

"  As,  at  the  present  time,  the  subject  of  chloroform  inhalation 
is  again  sub  judice,  I  feel  it  incumbent  upon  me  to  raise  my 
voice  against  its  employment  in  midwifery,  and  to  lay  before 
my  professional  brethren,  my  reasons  for  the  adoption  of  such 
a  course,  which  I  sincerely  trust  shall  have  some  weight  with 

•By  Robert  Johns,  A.B.,  M.D.,  T.C.D.,  Chairman  of  the  Midwifery  Court,  and  Ex- 
aminer in  Diseases  of  'Women  and  Children,  Koyal  College  of  Surgeons  in  Ireland, 
etc. 


CHLOROFORM   IN  LABOR.  477 

the  unprejudiced,  and  which,  may,  perchance,  call  the  more 
serious  attention  of  some,  if  not  of  all,  of  those  now  too  deeply 
wedded  to  its  use,  to  the  dangerous,  and  too  often  fatal  results, 
consequent  thereon,  in  which,  if  I  but  even  partially  succeed, 
I  shall  consider  myself,  well  repaid. 

"  From  experience,  repeated  observation,  and  the  published, 
as  also  the  otherwise  expressed  opinions  of  those  who  agree,  as 
well  as  those  who  disagree  with  me  upon  the  subject,  I  am 
firmly  convinced  that  chloroform,  when  inhaled  during  labor, 
very  fruitfully  disposes  to  hemorrhage,  puerperal  inflamma- 
tion, chest  affections,  and  to  other  diseases  detrimental  to  health 
and  life,  which  it  aggravates  if  given  during  their  presence. 
It  also  lays  the  foundation  of  diseases  to  arise  at  a  more  dis- 
tant period,  and  thus  increases  the  mortality  in  childbed,  and 
subsequent  thereto.  I  have  known  puerperal  inflammation 
frequently  to  have  followed  its  inhalation,  and  too  often  with 
a  fatal  result ;  in  fact,  some  years  since,  when  it  was  more 
fashionable,  and  was  given  with  a  more  lavish  hand,  a  great 
mortality  was  obtained  amongst  the  patients  of  some  few  men  who 
administered  it — so  much  so  that  a  popular  outcry  was  raised 
against  its  employment.  In  the  majority  of  those  cases,  puer- 
peral fever  was  the  cause  of  death,  which,  when  thus  raised, 
being,  as  I  firmly  believe,  always  infectious,  or  otherwise  com- 
municable, became  epidemicized,  after  which,  even  those  who 
wisely  refused  the  drug,  '  charmed  it  never  so  sweetly,'  were 
thus  inadvertently,  and,  in  some  instances,  hopelessly  pois- 
oned. 

"  In  support  of  these  positions,  I  shall  first  refer  to  the  sev- 
eral published  Reports  of  the  Dublin  Lying-in  Hospital.  We 
find,  on  reference  thereto,  during  the  masterships  of  Drs.  Col- 
lins, and  Johnson,*  when  chloroform  was  not  inhaled,  that  the 
mortality  was  much  less  than  during  that  of  Dr.  Shekleton,! 
when  this  '  pernicious  drug  was  used ' — as  thus  : — In  the  first 
report  are  recorded  16,414  deliveries  and  164  deaths,  or  1  in 
100 ;  in  the  second,  6,684  deliveries  and  65  deaths,  or  1  in  102 ; 


*  By  Drs.  Hardy  andM'Clintocb. 
f  By  Drs.  Sinclair  and  Johnston. 


478  ARTIFICIAL   ANAESTHESIA. 

whereas  in  the  third,  13,748  deliveries  are  given,  and  163  deaths 
or  1  in  84!  !  But  of  these  last  13,406  cases  were  not  chloro- 
formed, of  which  only  133  died,  or  1  in  100,  and  of  the  re- 
maining 342  who  took  the  drug,  30  died,  or  1  in  11 ! !  I  If, 
again,  we  examine  the  reported  cases  of  chloroform  adminis- 
tration by  Simpson,  and  Denham,  we  will  find  that  of  245 
cases  mentioned  by  the  former,  5,  died,  or  1  in  49 ;  and  of  56 
by  the  latter,  5  died,  or  1  in  11  ! !  And,  by  adding  all  these 
recorded  cases  together,  we  have  a  mortality  on  the  whole  of 
1  in  16 ! ! !  By  again  consulting  those  reports,  we  perceive 
that  in  Dr.  Collins"  mastership,  there  occurred  97  cases  of  post- 
partum inflammation,  or  1  in  169 ;  in  Dr.  Johnson's,  62  cases 
or  1  in  107  ;  but  in  Dr.  Shekleton's,  150  cases,  or  1  in  91.  Of 
those  150  cases  20,  followed  upon  chloroform  inhalation,  or  1 
in  17 ! !  and  in  the  remaining  130  cases,  in  which  it  was  not 
employed,  the  average  mortality  was  only  1  in  103.  In  Den- 
ham's  report,  we  find  4  cases,  or  1  in  14 ;  which,  with  all  the 
recorded  cases,  strikes  an  average  of  1  in  16^  ! ! ! 

"  We  also  find  that,  during  Dr.  Collins'  mastership,  puerperal 
convulsions  proved  fatal  in  the  proportion  of  1  in  6 ;  whereas 
in  that  of  Dr.  Shekleton,  when  under  chloroform  it  amounted 
to  1  in  3 ! !  and  in  Denham's  cases  to  2  in  3 ! ! !  or,  on  the 
whole,  to  1  in  2  J ! ! ! 

"It  appears,  that  during  Dr.  Shekleton's  tenure  of  oflBce,  post- 
partum hemorrhage  occurred,  but  once  in  every  257  cases  when 
chloroform  was  not  used;  yet  after  its  inhalation  this  compli- 
cation was  present  in  1  of  every  49  cases.  In  Dr.  Denham's  re- 
port, it  was  i^resent  in  1  of  every  19  cases;  making,  on  the 
whole,  an  average  occurrence  of  1  in  every  39|  cases. 

"  With  respect  to  the  mortality  after  perforation,  the  report  of 
Dra.  Hardy,  and  M'Clintock,  shows  1  fatal  case  in  every  6,  and 
that  of  Drs.  Sinclair,  and  Johnston,  1  in  every  5  ;  but  if  we  go 
a  little  below  the  surface  in  the  latter  report,  and  examine  into 
99  cases  of  perforation,  all  of  equal  severity  and  danger,  we 
shall  discover  that  of  the  29  cases  in  which  chloroform  was  in- 
haled 9  died,  or  1  in  3.]r ;  puerperal  inflammation  occurred  10 
times,  or  1  in  every  3  cases ;  and  hemorrhage  followed  in  3 
cases,  or  1  in  every  10 ;    whereas,  of  the  70  cases  in  which  this 


UTEEINE  ACTION   DURING   CHLOEOFOEM.        479 

drug  was  not  employed,  only  6  women  died,  or  1  in  every  12; 
puerperal  inflammation,  arose  only  in  3  cases,  or  1  in  every  23 ; 
and  in  no  case  did  hemorrhage  occur. 

''  Many  have  testified  to  the  fact,  that  uterine  action  has  been 
lessened,  and  even  caused  to  cease,  by  anaesthetics ;  as  also 
that  their  effect  on  some  is  not  commensurate  with  the  quanti- 
ty of  the  drug  employed — as  thus;  a  very  large  amount  not 
having  any  effect  on  some,  whereas  the  inhalation  of  a  very 
small  dose,  even  of  a  few  drops,  has  produced  almost  deep 
coma  in  others.  Dr.  Denham  says  : — '  In  some,  if  left  to  na- 
ture, the  labor  would  probably  have  been  completed  in  a  some- 
what shorter  space  of  time.  The  advantages  to  be  gained  by 
chloroform,  in  some  cases,  will  not  be  found  an  adequate  com- 
pensation for  the  loss  of  power  sustained  in  the  muscles  of 
animal,  or  organic  life  ;  and,  were  we  to  continue  its  use,  I  do 
believe  that  the  patients  would  remain  undelivered  for  hours, 
or  even  days.  The  cases  that  apparently  require  it  most — tedi- 
ous, and  difficult,  labors — are  those,  where  it  often  appears  to  be 
injurious,  by  weakening  the  pains  or  relaxing  the  muscles  of 
animal  life.'  Eigby  says  : — '  We  meet  with  cases,  every  now 
and  then,  where  chloroform  undoubtedly  retards  labor,  and  in 
some  cases  likely  to  call  for  the  use  of  the  forceps.' 

"  Dr.  Robert  Lee,  mentions  cases  in  which  '  uterine  contrac- 
tions were  arrested,  requiring  the  use  of  the  forceps  and  per- 
forator.' 

"  Tyler  Smith,  '  has  seen  chloroform,  stop  labor  midway.' 

"  In  some  of  the  cases  recorded  by  Sinclair,  and  Johnston, 
uterine  action  was  impaired. 

"  My  friend.  Dr.  Young,  of  Monaghan,  says,  in  a  letter  to  me : 
'  I  believe  chloroform  in  many  instances  to  delay  the  labor  by 
causing  the  pains  to  come  at  longer  intervals,  and  rendering 
the  expulsive  efforts  of  the  patient  less  efficient,  owing  to  her 
insensibility  to  suffering.' 

"  Merriman,  has  mentioned  a  case  in  which  '  the  uterus  was  so 
paralyzed,  that  it  failed  to  act  afterwards.' 

"  Snow,  says : — '  It  is  true,  that  a  full  dose  would  at  any  time 
suspend  uterine  action  for  a  fevf  minutes,  or  as  long  as  it  might 
be  kept  up.' 


480  ARTIFICIAL   ANAESTHESIA. 

"  Ferguson,  says  : — 'Chloroform  does  not  destroy  muscular 
action  because,  when  under  its  influence,  some  expel  urine  and 
faeces.'  Now,  from  this,  his  doctrine  must  be,  that  it  increases 
muscular  action ;  whereas,  I  take  it,  that  it  paralyzes  the 
sphincters. 

"  On  looking  into  Drs.  Sinclair  and  Johnston's  report,  we  find, 
'  two  cases,  in  which  version  was  very  difficult ;  and  two  others, 
in  which  that  operation  was  impossible,  where  chloroform  had 
been  inhaled.' 

"  Murphy  thus,  speaks: — 'In  a  case  of  version,  I  never  ex- 
perienced so  much  difficulty,  in  consequence  of  the  strong  con- 
tractions of  the  uterine  fibres  about  the  child.' 

"  Barnes'  remarks : — '  In  many  cases  it  does  not  facilitate  the 
operation  of  version,  the  uterus  resisting  the  introduction  of 
the  hand.' 

"Puerperal,  hysterical  and  epileptic  convulsions — mania,  par- 
alysis, and  insanity,  have  followed  on  its  use.  Cases  are  re- 
corded by  Montgomery,  Sinclair,  and  Denham,  in  which  puer- 
peral convulsions  occurred  after  its  employment.  Sinclair  gives 
two  cases  of  hysterical  convulsions,  in  one  of  which,  '  violent 
muscular  action  was  induced  ;  restlessness  continued  for  a  con- 
siderable time  after  the  inhaler  was  removed.' 

"  Murphy  states,  that  in  '  dentistry,  hysterical  women  have 
been  seized  with  fits,  when  under  its  influence.' 

"  Snow,  asserts,  that  'hysterical  patients,  as  soon  as  they  lose 
their  consciousness  from  the  effects  of  the  vapor,  are  sometimes 
attacked  with  a  paroxysm  of  hysteria.' 

"  Dr.  R.  Lee,  says: — '  Epilepsy  has  been  so  induced.' 

"Sinclair,  records  one  case  of  epilepsy. 

"Snow,  and  M.  Fix,  have  stated  '  that  persons  subject  to  epi- 
lepsy, are  likely  to  have  a  fit  brought  on  by  inhaling  chloro- 
form.' 

"  Ramsbotham, '  saw  three  cases  of  puerperal  mania  so  caused. 
A  friend  of  his  also  saw  one  similar  case.' 

"  Sutherland,  '  met  three  other  cases  similarly  produced.' 

"Tyler  Smith,  stated  'that  he  had  seen  mania  from  its  use.' 

"Parks,  relates  the  case  of  a  lady  who  had  chloroform  in  her 
third  labor.      '  She,  after  delivery,  complained  of  violent  pain 


OPINIONS   OF    DENHAM^    LEE   AND    OTHERS.       481 

in  the  head,  became  delirious,  tore  the  nurse's  gown  and  the 
bed-clothes  into  pieces,  and  was  perfectly  maniacal.' 

"  Mr.  Banner,  thus  speaks : — 'A  patient  became  delirious,  and 
continued,  so  during  the  day  and  greater  part  of  the  night, 
after  its  use.' 

"Hartman,  'saw  a  case  of  headache  terminating  in  paral- 
ysis, caused  by  this  drug.' 

"In  one  of  Dubois'  published  cases,  numbness  of  the  fingers, 
and  in  another  the  same  condition  of  the  legs,  supervened,  and 
had  not  subsided  at  the  end  of  twenty-four  hours. 

"  In  Denham's  report,  I  find  one  case  of  coma  after  chloro- 
formic  inhalation. 

"Dr.  R.  Lee,  says,  'that  insanity  has  followed  on  its  employ- 
ment ;  that  dangerous  and  fatal  peritonitis  and  phlebitis  have 
been  caused  by  its  inhalation.' 

"  Two  or  three  of  Deaham's  cases  were  seized  with  rigors  ; 
and  Lee,  mentions  '  others  with  dangerous  fits  of  syncope;' 
and  in  this  he  is  borne  out  by  the  following,  which  I  find  re- 
corded among  Denham's  cases : — '  While  inhaling,  the  pulse 
became  very  weak,  and  she  gave  no  signs  of  consciousness; 
and,  immediately  on  the  birth  of  the  child,  the  respiration  of 
the  patient  ceased,  and  the  pulse  became  imperceptible  ;  the 
application  of  cold  water  to  the  face  soon  revived  her,  and  she 
went  on  favorably  for  several  days ;  but  diarrhoea,  with  exten- 
sive inflammation  of  the  mucous  membrane  of  the  ilium,  set 
in,  and  she  died  on  the  fourteenth  day.' 

"Sinclair,  and  Johnson,  record  nearly  a  similar  case,  as  thus : 
'The  pulse  suddenly  became  imperceptible,  and  respiration 
appeared  to  have  ceased.  She  subsequently  died  of  phlebitis.' 
And  they  give  another,  in  which  collapse  occurred,  and  she 
died  with  symptoms  of  phlebitis. 

"  Tyler  Smith,  says  '  that  he  knew  two  ladies  in  whom  a  few 
drops  of  chloroform,  at  any  time,  would  produce  repeated 
fainting.' 

"  I  am  acquainted  with  a  lady,  who,  some  time  since,  had  a 
very  severe  attack  of  syncope,  from  taking  only  five  drops  of 
chloroform  in  a  draught. 

"  Dr.  Barnes  stated — '  That  he  had  himself  given  chloroform 
21 


482  ARTIFICIAL   ANAESTHESIA. 

to  facilitate  the  extraction  of  an  adherent  placenta,  and  had 
witnessed  such  exceeding  prostration  lor  eight  hours  after- 
wards, as  to  make  him,  and  another  ]  ractitioncr  who  assisted 
him,  api^rehensive  of  the  instant  death  of  the  patient.' 

"Many  are  of  opinion  that  the  inhalation  of  chloroform  pre- 
disposes to  laceration  of  the  perin?eum;  indeed,  some  of  the 
published  cases  would  tend  to  favor  this  idea.  In  Sinclair  and 
Johnston's  report,  we  iind  that,  in  the  recorded  cases,  it  occur- 
red once  in  27  cases;  and  when  not  employed,  the  accidtnt 
happened  only  once  in  93  cases.  In  the  same  work,  we  find  3 
cases  of  chest  affection,  aggravated  by  this  means,  two  of 
which  succumbed.  Dr.  Eingland,  one  of  the  Masters  of  the 
Coombe  Lying-in  Hospital,  in  reply  to  a  letter  from  me,  thus 
writes : — 

"  '  I  have  seen  chloroform  frequently  used  in  puerperal  con- 
vulsions, and  have  used  it  myself  in  connection  with  the  prac- 
tice of  the  Coombe  Lying-in  Hospital;  and  the  conclusion  I 
have  come  to  is,  that  I  will  never  again  use  it,  or  sanction  its 
use,  in  puerperal  convulsions.  I  have  observed  that,  however 
satisfactory  its  employment  may  ai:)pear  at  the  time,  it  has  been 
almost  invariably  followed  by  bronchitis,  within  48  hours,  and 
that  the  patients  have  sunk  rapidly  under  the  latter  afiection. 
I  have  seen  this  so  frequently,  that  I  cannot  but  look  on  chlo- 
roform, and  bronchitis,  under  the  circumstances  I  have  named, 
as  cause  and  effect ;  and  the  mortality  from  the  subsequent  bron- 
chitis, as  the  actual  result  of  the  employment  of  chloroform.' 

"  Ramsbotham,  relates  the  case  of  'a  lady  who  was  seized 
with  dyspnoea,  with  excessive  lividity  of  the  face,  and  all  the 
signs  of  engorgement  of  the  lungs  and  heart,  and  died  in  con- 
vulsions six  hours  after.' 

"  Murphy  has  published  a  case  nearly  similar ;  he  also  admits 
'that  vomiting,  nausea  and  headache  sometimes  follow  on  its 
use.'  Nausea  and  vomiting  were  also  present  in  some  of 
Denham's  cases. 

"  Rigby  states,  'that  intense  headache,  and  even  vomiting 
are  consequences  of  its  use.' 

"I  occasionally  use  a  blistering  fluid  which  contains  chloro- 
form, and  if  I  am  not  very  cautious  during  the  minute  1  am 


TYLEE   smith's   OPINION.  483 

employing  it,  I  am  certain  to  suffer  from  sick  headache  for  the 
remainder  of  the  day.  Not  long  since,  severe  vomiting  fol- 
lowed upon  the  inhalation  of  chloroform,  during  the  operation 
for  vesico-vaginal  fistula,  in  one  of  our  city  hospitals;  and,  in 
spite  of  all  remedies,  lasted  for  six  days.  It  is  needless  to  say 
that  the  operation,  in  consequence  thereof,  failed.  I  have  so 
often  seen  this  effect  of  the  drug  that  I  always  object  to  its  use 
in  operations  requiring  the  employment  of  sutures  upon  the 
female  genitals.  Thus,  it  is  evident,  that  such  a  complication 
existing  after  labor,  would,  like  severe  cough,  predispose  our 
patient  to  inflammation  in  parts,  for  whose  restoration  to  health, 
absolute  rest  is  required. 

"  Parks,  gives  the  case  of  a  'lady,  in  whom,  after  chloroform 
inhalation,  flooding  came  on  to  a  fearful  extent,  and  incessant 
sickness.  He  managed  to  extract  the  placenta;  and,  owing  to 
the  feeble  contractions  of  the  uterus  (and  this  latter  condition, 
he  is  confident,  it  often  produces),  he  was  kept  grasping  it,  for 
four  or  five  hours;  the  vomiting  continued  for  eight  hours,  with- 
out intermission  ;  the  headache  remained  for  weeks.' 

"  Tyler  Smith,  '  believed  that  post-partum  hemorrhage,  and 
retention  of  the  placenta,  occurred  more  frequently  after  its 
use  than  without  it.' 

"  Montgomery,  was  of  the  opinion  '  that  it  predisposes  to  re- 
tained placenta  and  hemorrhage.' 

"  My  friend.  Dr.  Young,  before  alluded  to,  says  : — '  I  have 
blamed  it  for  causing  a  longer  detention  of  the  placenta,  and 
for  occasional  after-hemorrhage,  owing  to  the  lazy,  and  ineffi- 
cient contraction  of  the  uterus.  After  its  use,  opiates  have 
very  little  effect ;  even  very  decided  doses,  in  any  form,  have 
not  been  followed  by  that  tranquillity  I  had  hoped  for,  in  that 
violent  pain  which  I  have  so  often  found  to  follow  operation 
when  chloroform  had  been  used.' 

"  Murphy,  speaks  of  making  pressure  on  the  uterus  to  expel 
the  placenta,  in  two  cases,  after  chloroform. 

"  Denham,  had  one  case  of  retained  placenta  after  its  employ- 
ment. He  says  : — '  We  had  no  reason  to  think  that  chloro- 
form predisposed  to  hemorrhage ;  on  the  contrary,  we  were 
impressed  with  the  idea  that  the  number  of  hemorrhagic  cases 


484  ARTIFICIAL   ANAESTHESIA. 

where  it  had  been  given,  were  rather  below,  than  above  the 
average,  in  ordinary  practice.'  This  statement  does  not  accord 
with  my  experience,  and  I  should  be  sorry  to  think  that  hem- 
orrhage so  frequently  complicated  labor, 'in  ordinary  practice,' 
as  once  in  every  nineteen  cases,  as  shown  by  his  report.  Some 
of  the  loudest  advocates  for  chloroform  inhalation  in  labor, 
have,  in  order  to  counteract  its  deleterious  effects  upon  uterine 
action,  recommended  the  co-administration  of  ergot  of  rye; 
which  practice,  reminds  me  of  the  astute  physician  who,  to  be 
sure  to  hit  his  patient's  disease,  prescribed  for  him  the  combi- 
nation of  a  stimulant  with  a  sedative,  and  a  purgative  with  a 
tonic.  But  I  hold  that  there  is  a  more  serious  objection  than 
this,  to  the  wholesale  use  of  ergot;  for  we  cannot  conceal  from 
ourselves  the  fact,  that  its  administration,  even  in  appropriate 
cases,  is  not  always  innocuous.  Some  years  since,  the  follow- 
ing case  came  under  my  knowledge: — Ergot  was  given  to  an 
unmarried  woman  to  facilitate  the  birth  of  her  first  child,  before 
her  father,  who  was  ignorant  of  her  condition,  had  returned 
home  to  his  dinner.  The  child  was  rapidly  expelled,  but 
sloughing,  to  a  frightful  amount,  followed,  and  placed  her  life 
in  jeopardy  for  days.  And  who  has  not  seen  the  child  sacri- 
ficed by  it?  For  this  reason,  it  has  now  become  almost  an 
axiom,  not  to  leave  a  female  undelivered  for  a  longer  period 
than  two  hours,  after  its  employment.  I  believe  that  ergot 
of  rye,  in  some  cases,  causes  incarceration  of  the  placenta  and 
hemorrhage,  and  in  others,  sinks  the  patient ;  the  uterus, 
afier  its  use,  often  remains  large  and  uncoutracted  for  days, 
which  state  not  unfrequently  terminates  in  imperfect  involu- 
tion of  the  uterus,  and  its  consequences ;  which  last  eflect  chlo- 
roform also  produces.  Many  believe  that  ergot,  besides  de- 
stroying the  child  at  the  time  of  its  birth,  acts  sometimes  other- 
wise deleteriously  upon  it,  by  inducing  disease — to  do  so  at  a 
shorter  or  longer,  subsequent  period — or  to  reduce  it  to  a  state 
to  which  death  would  be  preferable. 

"Dr.  Cat  let,  in  the  57th  volume  of  the  Edinburgh  Medical 
Journal,  page  83,  states  that  ergot  of  rye,  when  given  during 
labor,  causes  puerperal  convulbions,  hour-glass  contraction  of 
the  uterus,  and  infantile  hydrocephalus.     Amongst  the  cases 


DE,  beatty's  paper.  485 

of  the  last,  I  find  one  in  which  'symptoms  of  meningeal  in- 
flammation were  developed  on  the  19th  day,  and  the  child 
died  in  convulsions,  v^ith  coma,  on  the  second  day  following.' 
And  in  another,  '  the  symptoms  of  cerebral  derangement  set 
in,  suddenly,  on  the  21st  day,  and  the  child  died  on  the  third 
day  of  the  attack,  in  convulsions.' 

"  Dr.  Beatty,  in  a  paper  '  On  the  Influence  of  Ergot  of  Rye, 
on  the  Foetus  in  Utero,'  publithed  in  the  25th  volume  of  the 
Dublin  Medical  Journal,  page  201,  amongst  other  cases  after 
its  use  in  labor,  gives  the  following: — Case  7.  The  child  had 
convulsions  for  three  days  after  its  birth.  Case  9.  The  child 
had  convulsions  for  48  hours  after  birth.  They  then  subsided, 
but  left  the  child  in  a  state  resembling  paralysis,  with,  occa- 
sionally a  convulsive  motion  of  the  muscles  of  the  face  and 
limbs,  and  fixed  strabismus.  No  treatment  seemed  to  have 
any  eflect  upon  this  condition.  Twenty  days  after  its  birth, 
the  following  report  was  taken  : — '  This  child  has  remained  in 
a  state  of  insensibility  up  to  the  present  time  ;  the  strabismus 
has  lately  disappeared,  but  it  seldom  opens  its  eyes.  The  limbs 
are  apparently  powerless.  It  makes  no  effort  to  suck,  but  it 
swallows  breast-milk  with  difficulty  when  put  into  its  mouth. 
The  difiiculty  is  increasing  ;  the  bowels  act  naturally.'  In  this 
state,  the  child  lingered  on,  until  tlie  25th  day,  when  it  died. 
Case  12.  This  child,  he  firot  saw  when  three  years  old ;  '  it  then 
had  an  idiotic  countenance,  and  was  never  free  from  spasms 
and  palsy,  commencing  from  its  birth.' 

"  Cusack,  and  others,  have  also  testified  to  the  deleterious  ef- 
fects of  this  drug,  upon  the  cerebro-spinal  system  of  the  infant. 

"  Dr.  Snow,  says,  that  '  chloroform  is  a  volatile  spirit,  and 
that  half  an  hour  after  its  application  no  traces  of  it  could  be 
found  in  the  system.' 

"Now,  in  refutation  of  this  assertion,  Dr.  Eamsbotham  men- 
tions the  case  of  '  a  lady  who,  for  four  or  five  days  after  its 
use,  could  not  get  rid  of  the  smell.' 

"  Dr.  Aveling,  speaks  of '  a  lady  who  had  chloroform  in  three 
labors,  all  of  whose  children,  when  unwell,  had  for  years  aft- 
erwards the  smell  distinctly  on  their  breaths.  This  lady  would 
never  take  it  again.' 


486  ARTIFICIAL   AX^STIIESIA. 

"In  a  monograph  by  the  writer,  on  'Blistering  the  Os  and 
Cervix  Uteri,'  published  in  the  i\I:iy  number  of  the  Dublin 
Quarterly  Journal,  of  the  year  1857,  cases  are  mentioned  of 
females  having  had  the  smell  of  chloroform  on  their  breaths, 
evident  to  their  friends  as  well  as  to  themselves,  and  of  others 
having  experienced  its  taste,  lasting,  in  both  instances,  for 
days  after  the  blistering  fluid,  containing  that  drug,  had  been 
employed. 

"  When  sulphuric  ether  was  first  employed  as  an  anaesthetic 
in  this  country,  a  medical  student  inhaled  it  as  an  experiment 
in  this  city,  and  the  smell  of  it  was  evident  on  his  breath,  to 
any  one  who  spoke  with  him,  for  nearly  a  week  after  its  em- 
ployment. 

"Dr.  Jackson,  (an  American)  thus  writes  upon  the  subject: — 
'When  chloroform  is  inhaled  into  the  lungs,  the  oxygen  is 
abstracted  from  the  blood,  aud,  combining  with  the  formyl, 
makes  formic  acid,  while  the  chlorine  combines  with  the  blood 
as  a  substitute  for  oxygen.  Thus  a  portion  of  the  blood  be- 
comes chemically  changed,  disorganized,  and  rendered  unfit 
for  its  vital  functions.  I  have  now  a  phial  of  blood,  taken 
from  a  young  lady  killed  by  the  inhalation  of  pure  chloroform, 
before  me,  it  having  been  kept  in  my  oSice,  exposed  to  tem- 
peratures from  the  freezing  point  to  above  80°,  for  more  than 
six  years,  and  yet  it  has  not  decomposed,  nor  has  a  single  blood- 
globule  settled  to  the  bottom  of  the  phial,  nor  has  the  color 
changed  in  the  least.'  It  has  been  denied,  that  females,  when 
under  the  influence  of  chloroform,  make  use  of  improper  and 
indecent  language.  Now,  I  never  shall  forget  the  case  of  a 
lady  I  saw,  in  consultation,  a  couple  of  years  ago,  with  a 
hospital  surgeon,  who,  when  chloroformed,  threw  her  arms 
around  him  in  the  most  endearing  manner,  and  made  use  of 
language  which  would  make  her  blush  if  in  her  senses,  of 
which,  I  hope  sincerely,  she  was  never  made  cognizant. 

"  Denham,  says: — 'There  are  cases  in  which  chloroform  ap- 
peared to  be  not  only  useles*,  but  when  persevered  in,  posi- 
tively injurious.'  And  again: — 'In  giving  chloroform  we 
incur  a  certain  amount  of  present  danger,  and  perchance  of 
remote  ill  effects.' 


DR.   BARNES'   OPINION.  487 

"Dr.  Robert  Lee,  in  reply  to  a  letter  from  me,  says: — 'I 
could  give  you  a  great  number  of  cases,  in  which  chloroform 
was  not  only  injurious,  but  fatal.' 

"  Dr.  Gream,  said  : — '  He  agreed  with  Dr.  Lee,  in  saying  that 
we  were  quite  unacquainted  with  one-tenth  of  the  evil  effects 
which  had  resulted  from  the  use  of  chloroform,  particularly  in 
Scotland.' 

"  Dr.  Duncan,  in  a  letter  to  Dr.  Lee,  thus  writes : — '  Your 
case  of  chloroform  death  in  midwifery  is,  to  the  best  of  my 
belief,  not  the  only  one  in  Scotland.  I  was  called,  too  late,  to 
a  case  which  died  suddenly  while  taking  it  in  small  quantity.^ 

"  Dr.  Campbell,  of  Ayrshire,  records  another  case  of  death  in 
labor  from  its  use,  Mr.  Carter,  says  'that  in  two  cases  its  ef- 
fects would  appear  to  have  been  pernicious.' 

"  Prof.  Faye,  of  Christiana,  has  also  recorded  a  fatal  case  of 
labor  after  its  use. 

"  Dr.  "Barnes,  says  : — '  In  ordinary  forceps  cases,  chloroform 
certainly  is  not  required,  either  to  facilitate  the  operation,  or  to 
allay  pain.'  Indeed,  by  its  use  in  such  cases,  we  lose  one  very 
valuable  indication  by  our  patient's  want  of  sensibility.  Dr. 
Chas.  Kidd,  evidently  does  not  consider  its  use  devoid  of  dan- 
ger, as  he  advises  the  physician  who  administers  it  '  always 
to  carry  in  his  poctet  a  portable  galvanic  chain  or  battery.' 
Drs.  Kidd,  and  Richardson,  are  reported  as  having  seen  many 
deaths  after  its  employment;  and  the  former  gentleman  'to 
have  seen  about  300  cases  restored  to  life,  or  rescued  after  they 
had  been  pronounced  dead.'  I  would  ask,  in  the  name  of 
common  sense,  is  it  within  the  bounds  of  reason  to  believe  that 
a  medicine  can  be  employed  innocuously  with  the  pregnant 
female,  when  confessedly  its  use  has  often  been  followed,  not 
only  by  dangerous,  but  ev^en  fatal  results  under  other  circum- 
stances, as  testified  to  by  Drs.  Kidd  and  Richardson,  amongst 
many  others,  as  also  by  almost  every  periodical  we  take  up? 
Dr.  Snow,  in  speaking  of  his  imagined  advantage  of  chloro- 
form over  opium  in  version  cases,  thus  writes : — '  If  50  or  60 
drops  of  laudanum  were  given,  the  patient  remained  under 
its  influence,  more  or  less,  for  forty-eight  hours.'  Now,  in 
this  I  must  join  issue  with  the  doctor;  for  I  am,  and   have 


488  ARTIFICIAL   ANAESTHESIA. 

been  for  years,  in  the  habit  of  giving  such,  and  even  much 
larger  closes  in  those  cases,  as  also  in  hemorrhage,  and  I 
never  yet  saw  such  a  result,  or  one  at  all  approaching  to  it. 
We  have  been  told,  that  across  the  Tweed,  death  has  not,  in 
any  instance,  followed  upon  the  inhalation  of  chloroform  in 
labor,  whereas  some  have  been  since  recorded;  and  not  very 
long  ago  I  was  informed,  by  more  than  one  physician  prac- 
ticing in  Scotland,  that  many  have  so  occurred  there,  but  not 
made  public,  yet  well  known  to  the  profession.  It  is  also  a 
fact  that  some  who  have  written  favorably  on  its  use,  have 
sirtce  changed  their  opinions,  but  have  not  said  so  publicly; 
and  some  give  it  only  in  name,  or  as  has  been  styled  ci  la  Bdne. 
The  following  is  so  appropriate  here,  that  I  cannot  avoid  quoting 
it  from  Denham:  'That  chloroform  may  be,  and  sometimes 
is,  given  for  the  purpose  of  amusing  patients,  and  making 
them  believe  that  they  are  saved  from  a  vast  amount  of  pain, 
when  in  reality  they  have  scarcely  inhaled  a  single  breath  of 
it,  I  doubt  not.' 

"  We  very  frequently  see  safer  and  better  recoveries  after 
tedious,  and  painful,  than  after  rapid  and  painless  labors,  and 
the  latter  are  not  the  less  likely  to  be  seriously  complicated; 
indeed,  in  former  days,  when,  happily  for  the  parturient  female, 
chloroform  was  unknown,  and  when  meddlesome  midwifery 
was  strongly  reprobated,  such  an  opinion  was  entertained. 
Apropros,  I  have  two  patients — one  the  mother  of  five,  the 
other  of  four  children — who  always  have  rapid  and,  I  may 
say,  painless  labors,  but  which  are  invariably  followed  by 
alarming  hemorrhage,  by  no  means  an  unusual  occurrence,  as 
already  shown,  after  chloroform  inhalation,  besides  being  ad- 
mittedly a  fruitful  predisposing  cause  of  puerperal  inflamma- 
tion. In  the  employment  of  ana;sthetic  agents,  during  instru- 
mental delivery,  we  deprive  ourselves  of  a  very  valuable 
indication  in  the  loss  of  our  patient's  sense  of  feeling,  which 
the  following  cases  forcibly  illustrate;  for  had  such  means 
been  resorted  to  in  either,  it  must  be  evident  to  all,  even  to 
the  most  skeptical,  that  the  consequences  should  have  been 
most  dis.astrous:  Mrs.  D.  had  a  very  tedious  labor  with  her 
first  child.     When  about  thirty-six  hours  in  labor,  the  os  uteri 


DR.  Montgomery's  opinion.  489 

was  fouQd  thinned  and  spread  tightly  over  the  head  of  the 
child,  dilated  to  about  the  size  of  a  shilling,  but  directed  ob- 
liquely backwards  and  upwards,  so  located  as  only  to  be  f  mnd 
by  the  well-educated  and  practiced  finger.  Her  medical  at- 
tendant, having  failed  to  discover  the  real  state  of  matters, 
took  it  for  granted  that  he  only  felt  the  head,  which  had 
passed  through  the  fully  dilated  os,  and  proceeded,  without 
further  delay,  to  deliver  her  with  the  forceps;  but  from  the 
great  pain  which  she  experienced  from  the  application  of  its 
blades  on  the  head  so  clothed,  he  was  obliged  to  desist;  and, 
being  much  alarmed,  he  sought  for  further  assistance,  after 
which  the  nature  of  the  case  was  discovered,  when,  of  course, 
all  interference  was  given  over  for  the  time;  but  eventually 
had  recourse  to  destructive  instruments.  The  other  was  the 
case  of  Mrs.  M.,  very  similar  to  the  former;  but  the  perfo- 
rator was  the  instrument  employed,  which  the  medical  gentle- 
man pushed  into  the  cervix  expanded  over  the  head,  when 
her  piercing  cries  and  some  slight  bleeding  caused  him  to 
look  more  narrowly  into  the  state  of  the  parts.  She  was, 
however,  afterwards  naturally  delivered,  and  had  a  good  re- 
covery. 

"  At  page  333,  of  the  Dublin  Quarterly  Journal  of  Medical  Sci- 
ence, far  May,  1849,  in  the  late  Dr.  Montgomery's  essay  upon 
^ The  Indiscriminate  Administration  of  Anaesthetic  Agents  in 
Midwifery,'  we  find  a  somewhat  similar  case  recorded,  in 
which  the  medical  man  mistook  the  attenuated  anterior  sec- 
tion of  the  cervix  uteri  for  the  membranes,  which  he  was  en- 
deavoring to  perforate  with  his  nail,  when  the  lady's  cries 
arrested  him. 

"  Even  though  it  were  possible  to  divest  chloroform  of  its 
dangers,  it  does  not,  as  has  been  already  shown,  always  pro- 
duce the  advantages  expected  from  its  use,  as  in  version ;  for, 
indeed,  not  a  few  instances  have  been  recorded  of  its  having 
been  an  impediment  to  this  operation,  which  in  some  cases 
could  not  be  overcome.  I  cannot  see  any  advantage  derivable 
from  the  inhalation  of  this  poisonous  drug,  in  cases  of  retained 
placenta,  as  generally  such  a  complication  is  caused  by  inac- 
tion of  the  uterus;  and  our  object,  therefore,  ought  to  be  to 

21* 


490  ARTIFICIAL,   ANvESTHESIA. 

induce  uterine  action,  surely  not  further  to  paralyze  it.  Such 
treatment  reminds  me  of  a  case  which  I  was  called  to  see 
twenty  years  ago.  Tlie  placenta  had  been  retained  for  six 
hours,  and  some  draining  was  going  on.  The  lady's  medical 
adviser  was  looking  on  very  complacently,  and  dosing  her 
wiih  tartar  emetic.  Of  course,  there  was  not  any  difficulty  ia 
the  extraction;  but  puerperal  inflammation  set  in  on  the  sec- 
ond day,  from  which  she  eventually,  but  slowly  recovered. 
Every  practical  man  hails  after-pains  as  salutary,  especially 
after  quick  and  painless  labors,  and  would  not  dream  of  inter- 
fering with  their  wholesome  action,  unless  very  severe,  for 
some  hours  after  delivery;  yet  those  misguided  chloroformists, 
think  nothing  of  interfering  with  that  safe  action  at  times, 
when  the  advent  of  hemorrhage  would  complicate  matters 
more  seriously.  Trie  other  objections  to  its  use  at  other  times, 
under  certain  circumstances,  are  equally  admissible  here.  I 
think  I  have  now  demonstrated  that  chloroform  inhalation  is 
far  from  being  a  safe  remedy  in  child  bed,  and  should  not  then 
be  employed."  {Dublin  Quarterly  Journal  of  Medical  Science, 
May,  1863.) 

Effects    of    Prolonged    Cliloroforin    Anaesthesia 

on    Dogs. 

Further  experiments  on  the  effects  of  prolonged  chloroform 
anaesthesia  on  dogs  have  recently  been  made  by  Dr.  Strassman, 
which  appear  to  confirm  the  views  of  Dr.  Ungar.*  Dr.  Strassman 
found  that  the  first  organ  to  be  affected  was  the  liver,  then  the 
heart,  and  after  that  other  viscera.  The  nature  of  the  morbid 
change  was  not  a  fatty  degeneration,  but  fatty  infiltration.  The 
actual  cause  of  deavh  in  fatal  cases  appeared  to  be  the  cardiac  af- 
fection, as  in  all  such  a  very  marked  degree  of  change  was  found 
in  the  heart.  In  non-fatal  cases,  the  morbid  change  was  found 
to  have  disappeared  in  a  few  weeks'  time.  When  morphine 
was  given  previously  to  the  chloroform,  less  of  the  latter  was 
required,  and  consequently  the  changes  produced,  were  not  80 
considerable  as  when  the  ordinary  amount  was  given.  Animals 
suffering  from  hunger,  loss  of  blood,  etc.,  were  especially  pre- 

*See  Uugar,  Experiments  Under  Chloroform. 


DEATH    FROM    MIXTURE.  491 

disposed  to  the  morbid  changes  due  to  chloroform. — Lancet, 
July  20,  1889. 

An  Abstract  of  the  Reports  of  Recent  Deaths  from 
a  Mixture  of  Ether  and  Chloroform. 

A  death  of  a  lady  had  occurred  in  the  practice  of  Dr.  East- 
ham,  a  dentist  of  Boston,  causing  much  excitement  in  profes- 
sional circles.  The  death  had  taken  place  about  noon,  but 
very  few,  except  those  particularly  interested,  were  aware  of  it 
till  the  next  day.  The  coroner,  Dr.  Ainsworth,  who  was  called 
in  directly  after  the  accident,  formed  a  jury  of  physicians  and 
apothecaries,  and  ordered  an  autopsy.  This  was  made  the  next 
morning  by  Dr.  R.  H.  Fitz,  pathologist  to  the  Massachusetts 
General  Hospital ;  and  on  the  same  day  the  jury  met,  and, 
having  viewed  the  body,  adjourned  until  the  14th.  The  anaes- 
thetic was  either  chloroform  or  a  mixture  of  chloroform  and 
ether.  The  latter  proved  to  be  the  one  used.  The  jury  met 
again  on  the  14th,  and,  having  heard  a  part  of  the  evidence, 
readjourned  till  the  evening  of  Wednesday  the  19th.  Instead 
of  death  resulting  from  ether,  it  was,  as  proved  by  analysis,  due 
to  chloroform,  and  the  coroner's  jury  presented  the  following 
verdict : — "  Death  was  caused  by  the  inhalation  of  chloroform, 
administered  in  a  mixture  of  chloroform  and  ether." 

Dr.  Henry  Buren,  of  Chicago,*  gives  the  following  version  of 
a  death  which  took  place  in  that  city  from  the  inhalation  of  a 
mixture  of  ether  and  chloroform : — 

"  Mrs.  B.,  aged  32,  American,  had  suffered  from  fistulse  in  ano 
for  six  months.  On  the  22d  of  November  last,  I  operated  on 
her,  finding  at  this  time  two  artificial  openings  into  the 
rectum,  one  on  either  side  of  the  anus.  Dr.  A.  Groesbeck  ad- 
ministered the  anaesthetic,  which  consisted  of  equal  parts  of 
sulphuric  ether  and  chloroform.  The  operation  was  performed 
in  a  few  seconds.  The  patient  exhibited  no  alarming  symp- 
toms while  under  the  influence  of  the  anaesthetic,  and  revived 
in  the  usual  time. 

"  On  the  morning  of  the  30th  of  November,  eight  days  after 

*  Chicago  Medical  Journal,  February,  1878. 


492  ARTIFICIAL   ANAESTHESIA. 

the  operation,  I  desired  to  make  a  thorough  examination  of 
the  wounds  and  renew  the  dressing,  and  in  this,  as  in  some  of 
the  previous  dressings,  the  patient  insisted  upon  partial  immu- 
nity from  pain.  To  this  end  I  commenced  to  administer  upon 
a  napkin  two  pans  of  sulphuric  ether  and  one  of  chloroform. 
After  a  few  inhalations  the  patient  became  violently  intoxi- 
cated, and  resisted,  with  great  force,  all  efforts  to  quiet  her,  de- 
manding in  the  language  of  one  in  delirium,  to  be  let  alone. 
I  immediately  ceased  to  administer  the  anaesthetic,  and  with 
great  effort  prevented  her  from  jumping  from  the  bed.  The 
face  became  at  first  turgid,  the  whole  body  convulsive,  and  in 
a  few  seconds  the  patient  was  dead. 

"  All  of  the  means  usually  resorted  to  were  employed  to  re- 
store action  of  the  vital  functions ;  artificial  respiration,  ele- 
vating the  lower  extremities,  dashing  cold  water  in  the  face, 
drawing  forward  the  tongue,  spirits  of  ammonia  applied  to  the 
nostrily,  and,  finally  a  galvanic  battery,  which  was  conveniently 
at  hand,  but  to  no  avail. 

"  I  have  to  say  in  justice  to  the  record  of  this  case,  that  the 
patient  had  for  many  years  habitually  partaken  of  opium.  At 
the  time  of  her  unfortunate  death  she  could  take  at  each  dose 
from  two  to  three  grains  of  morphia.  During  the  time  she  was 
under  my  care,  one  half  grain  doses  of  morphia  were  prescribed 
at  proper  intervals,  but  she  asserted  that  this  quantity  did  not 
sufficiently  support  her,  and  through  her  nurse,  and  by  stealth, 
she  secured  additional  quantities  from  the  neighboring  drug- 
stores, and  took  the  same  daily  without  my  knowledge  or  con- 
sent. 

"  I  am  now  of  the  opinion  that  the  patient  had  taken  an  un- 
usually large  dose  of  morphia  on  the  morning  other  death,  and 
that  the  combined  influence  of  this  overdose  and  the  addi- 
tional paralyzing  effects  of  the  anaesthetic  caused  cardiac 
syncope,  and  that  this  was  the  cause  of  death. 

"A  woman  aged  forty-six,  extremely  fat,  and  of  slow  intelli- 
gence, although  having  complained  of  shortness  of  breath,  was 
not  known  to  be  the  subject  of  organic  heart-disease.  She  was 
to  be  operated  upon  for  senile  cataract.  A  mixture  of  chloro- 
form and  ether,  in  a  modified  Clover's  apparatus,  was  being  ad- 


ACCIDENTS   TEOM   THE   A.-C.-E.    MIXTURE.       493 

ministered  by  the  house  surgeon.  From  the  commenceraentof 
the  administration,  respiration  was  noticed  to  be  shallow,  but 
there  was  struggling.  The  pulse  was  feeble,  but  not  intermit- 
tent. There  was  some  slight  lividity  of  cheeks  and  forehead. 
Chloroform  was  at  once  removed  and  a  few  whiifs  of  pure  ether 
administered  as  a  stimulant.  Other  means  for  circulation  were 
tried,  but  in  vain  ;  the  patient  died.  At  the  post-mortem  ex- 
amination the  heart  was  found  flaccid  and  empty;  the  mitral 
valve  was  contracted;  the  aortic  valves  were  incompetent;  kid- 
neys fatty  and  granular." — {Med.  Times  and  Gazette,  August 
18th,  1876.) 

Accidents  Accompanying-  the  Use  of  tlie  A.-C.-E. 
Mixture.  * 

" In  the  spring  of  1865,  while  stationed  at  the  U.  S.  A.  'Sum- 
mit' House  General  Hospital,  Philadelphia,  the  staff  were 
performing  an  amputation  of  the  leg.  At  the  suggestion  of 
Surgeon  Joseph  Taylor,  in  charge,  the  A.-C.-E.  mixture  was 
used.  The  anaesthetic  was  administered  by  Surgeon  A.  A.  Lea- 
vitt,  Executive  Officer  of  the  Hospital.  During  the  operation, 
the  patient's  respiration  failed.  The  condition  became  so 
alarming  that  the  operation  was  temporarily  discontinued,  and 
all  present  turned  their  attention  to  restoring  the  patient.  Ar- 
tificial respiration,  cutaneous  excitation,  and  inhalation  of 
fumes  of  ammonia,  fortunately,  were  successful.  The  opera- 
tion was  then  finished,  with  the  patient  only  partially  uncon- 
scious. For  many  years  I  had  not  used  this  mixture,  using 
either  ether  alone,  or  the  mixture  of  ether  two  parts,  chloro- 
form one  part,  by  weight ;  or,  rarely,  chloroform  alone. 

"During  the  past  two  years  I  have,  on  several  occasions,  used 
the  A.-C.-E.  mixture  with  gratifying  results,  being  led  to  use  it 
again  by  the  favorable  reports  given  by  various  authorities. 
During  the  summer  of  1886,  I  was  removing  cancerous  mam- 
mary and  axillary  glands — assisted  by  Drs.  Martin  and  Ches- 
ney,  of  Cairo,  West  Virginia.  To  Dr.  Chesney  was  intrusted 
the  administration  of  the  anaesthetic,  which  was  the  A.-C.-E. 

*  W.  H.  Sharpe,  M.D.,  Medical  News,  March  5,  1887,  p.  237. 


494  ARTIFICIAL   ANAESTHESIA. 

mixture.  During  the  operation  I  had  requested  him  to  discon- 
tinue the  anaesthetic,  as  the  patient  was  sufficiently  under  the 
influence.  This  he  did ;  he  had  his  finger  on  the  pulse,  and 
devoted  his  entire  attention  to  the  patient's  condition.  The 
mammary  gland  had  been  removed — care  being  taken  by  Dr. 
Martin  to  prevent  entrance  of  air  into  the  veins.  J  noticed  the 
extreme  pallor  of  the  patient's  face,  and  simultaneously  Dr. 
Chesney  said  the  pulse  had  failed,  so  as  to  be  inappreciable.  I 
immediately  placed  a  bottle  of  nitrite  of  amyl  to  her  nostrils — 
respiration  was  good.  Asking  Dr.  Martin  to  hold  it  there,  I 
prepared  a  hypodermatic  syringe  with  20  m.  of  tr.  digitalis,  and 
injected  it  in  the  precordial  region.  Dr.  Martin  meantime  an- 
nounced a  slight  recovery  of  pulse.  I  next  administered  sev- 
eral syringefuls  (hypodermatically)  of  whiskey,  and  we  had  the 
pleasure  of  seeing  the  patient  rally  from  this  heart-failure — 
due,  I  think,  to  the  depressing  influence  of  the  chloroform.  It 
was  carefully  administered — with  a  sponge  in  a  cone — i.e.,  a 
towel  stiflTened  with  a  sheet  of  paper  in  its  folds ;  the  sponge 
was  held  in  its  place  in  the  apex  by  transfixing  with  long  pins 
to  prevent  it  falling  down  on  the  patient's  face.  The  chloro- 
form and  ether  were  of  reliable  manufacture.  It  afterward 
developed  that  at  this  time  the  liver  was  involved  in  secondary 
cancerous  inflammation,  from  which  the  patient  succumbed  a 
few  weeks  after  recovery  from  the  operation. 

"A  more  recent  case  of  death  from  a  viixfure  of  ether  and  chlo- 
roform is  reported  in  the  Philadelphia  Medical  Times,  March  15, 
1879,  by  I.  A.  Cleary,  Assistant  Surgeon  U.S.A.  Private  H. 
D.  B.,  Co.  19,  U.  S.  Infantry,  aged  33,  large,  robust,  addicted  to 
liquor.  Injury  of  middle  finger,  right  hand,  resulting  in  gan- 
grene; decided  to  amputate.  A  mixture  of  equal  parts  of  ether 
and  chloroform  [weight  or  measure  not  stated).  Two  ounces 
whiskey  were  given  ten  minutes  prior  to  inhalation.  The  an- 
issthetic  was  administered  on  a  piece  of  Hut  covered  with  a 
small  towel  held  square.  He  personally  administered  the  mix- 
ture, while  the  steward  observed  the  pulse ;  air  was  freely  ad- 
mitted ;  he  inhaled  freely.  About  two  drachms  were  first 
poured  on  the  cloth,  but  with  no  apparent  effect  {he,  evidently, 
receiving  nothing  but  ether).   Shortly  after  about  the  same  quaa- 


CHLOROFORM   AND   MORPHIA.  495 

tity  was  poured  on;  he  observed  that  'he  did  not  feel  it.' 
After  a  time  abeut  the  same  quantity  was  again  poured  on.  A 
further  quantity  was  poured  on  the  cloth  (say  in  all  ^viii) 
when  he  began  to  laugh,  followed  by  attempts  to  articulate, 
and  made  strong  gesticulations  with  his  arms.  He  now  passed 
to  a  state  of  unconsciousness,  when  the  pulse  was  not  perceived. 
This  was  followed  by  relaxation  and  death.  At  once  the  anaes- 
thetic was  removed,  cold  water  dashed  in  the  face.  He  adds, 
'  everything  I  ever  heard  of,  saw  or  read,  appropriate  for  such 
a  case,  was  done,  but  to  no  effect.'  He  states  as  the  cause  of 
death,  paralysis  of  the  heart.  (I  think  it  was  syncope  from 
the  chloroform.)  " 

Chloroform  and.  Morpliia. 

At  a  very  early  period  this  mixed  narcosis  of  morphia,  and 
chloroform,  was  proposed  by  Nusbaum,  as  being  especially  use- 
ful for  operations  on  the  mour.h  and  jaws,  in  which  blood  is  apt 
to  flow  into  the  trachea  or  down  the  oesophagus  into  the  stom- 
ach, and  subsequently  to  cause  vomiting. 

A  subcutaneous  injection  of  morphia,  from  a  quarter  to  half 
a  grain,  is  given  as  soon  as  the  patient  is  placed  upon  the  oper- 
ating table,  and  immediately  afterward  the  administration  of 
chloroform  is  commenced.  After  inhalation  for  about  five  min- 
utes, the  operation  may  usually  be  begun,  but  the  chloroform 
must  be  renewed  at  intervals.  The  patients  lose  all  sensibility 
to  pain,  but  evidently  retain  a  considerable  degree  of  conscious- 
ness, and  control  of  voluntary  movements.  This  mixed  narco- 
sis has  been  employed  successfully,  as  far  as  the  annihilation 
of  pain  is  concerned.  Paralysis  of  the  heart,  too,  is  less  apt 
to  happen,  the  risk  of  the  occurrence  of  this  accident,  and  of 
asphyxia  as  well,  being  lessened  in  proportion  to  the  smallness 
of  the  dose  of  the  ansesthetic  required  to  cause  and  reproduce 
the  antesthesia.  It  is  pointed  out  that  this  method  makes  chlo- 
roform as  safe  to  use,  as  ether,  and  that  in  tropical  countries, 
especially  India,  where  operations  have  to  be  performed  at  a 
temperature  very  little  below  the  boiling-point  of  ether,  there 
is  practically  no  choice  of  anaesthetics. 

The  above  dose  of  morphia  is  too  large  for  safety,  as  there 


496  ARTIFICIAL   ANESTHESIA. 

are  many  persons  on  whom  even  one-quarter  of  a  grain  of  mor- 
phia, hypodermically,  will  act  as  a  powerful  poison,  while  half 
a  grain  even  produces  death.  The  injection  of  morphia  should 
be  small,  say  from  one-eighth  to  one-quarter,  and  this  should 
be  given,  according  to  Claude  Bernard,  from  forty  minutes  to 
one  hour  before  the  chloroform  is  employed.  The  question 
should  always  be  put  to  the  patient,  Have  you  ever  employed 
morphia,  and  if  so,  what  effect  has  it  upon  you  ?  The  great  ad- 
vantage claimed  for  this  method,  is  that  the  stage  of  excitement 
is  rendered  always  nil,  and  less  chloroform  is  needed  to  induce 
sleep  than  under  ordinary  circumstances.  It  must  always  be 
borne  in  mind,  that  nausea  and  vomiting  are  not  uncommon  at 
the  commencement,  if  the  morphia  is  quickly  absorbed.  This, 
with  the  vomiting  which  accompanies  chloroform,  will,  we  fear, 
be  apt  to  complicate  a  delicate  operation,  and  then  you  have 
the  double  risk  of  two  such  poisonous  agents. 

Ether  and  Morphia. 

Reliable  authorities  recommend  the  combination  of  tbe^e 
two  agents,  but  in  our  experience,  and  that  of  several  friends 
■ — especially  the  late  Dr.  Albert  Smith,  of  this  city — the 
combination  of  opium  or  morphia  with  ether,  although  pro- 
longing the  anaesthesia,  has  a  great  tendency  to  produce  res- 
piratory failure,  and  has,  in  more  than  one  instance,  been  fol- 
lowed by  death.  In  a  recent,  severe,  and  prolonged  operation 
upon  the  brain,  by  a  colleagueof  ours,  in  the  Jefferson  Medical 
College  Hospital,  he  had  administered  to  his  patient  ether,  as 
the  ansestnetic,  with  one-quarter  of  a  grain  of  morphia  hypo- 
dermically, one  and  a  half  hours  previously. — Medical  News, 
December  2i,  '88.  Just  before  recovering,  consciousness  vom- 
iting took  place.  The  combined  effect  of  the  operation,  the 
opium,  and  ether,  produced  an  alarming  amount  of  shock  and 
depression  of  the  vital  forces,  with  arresc  of  respiration,  and 
only  by  the  vigorous  use  of  artificial  respiration,  and  the 
battery,  atropia,  digitalis  and  whiskey,  hypodermically,  hot 
water  enema,  etc.,  was  a  fatal  termination  averted. 

In  criticising  his  procedures,  Dr.  Nancrede,  makes  the  fol- 


WAENING,   MIXED   MOEPHIA    AND   ETHER.      407 

lowing  statement:  "  I  believe  that  morphia  was  injurious,  and, 
conjoined  with  the  ether,  tended  to  produce  the  marked  respi- 
ratory failure.  Anaesthesia,  especially  when  induced  by  ether, 
and  preceded  by  morphia,  should  never  be  prolonged  a  mo- 
ment more  than  necessary,  and  should  not  be  pushed  to  its 
extreme  limits." 

This  combining  anaesthetics  with  opium  preparations,  meets 
a  critic  in  Dr.  E.  H.  Jacob,  who  writes  to  the  British  Bledical 
Journal,  the  following  w^arning:  "  May  I  utter  a  word  of  warn- 
ing on  the  combined  effects  of  ether,  and  opium?  Several 
cases  have  recently  come  to  my  knowledge — the  details  of 
which,  I  hope,  will  soon  be  published — in  which  death  fol- 
lowed a  short  time  after  the  administration  of  ether  to  patients 
under  the  influence  of  opium.  In  the  table  of  deaths  from 
ether,  which  you  have  published,  out  of  six  cases  in  which 
death  could  be  directly  attributed  to  the  anaesthetic,  two 
were  cases  of  hernia,  and,  therefore,  niost  probably  under  the 
influence  of  opium.  Whether  it  be  a  case  of  this  kind,  or 
morphia  be  given  subcutaneously,  in  order  to  obtain  the  bene- 
fits of  'mixed  anaesthetics,'  ether  is  not  without  danger;  and 
the  patient  should  be  carefully  watched,  after  the  operation, 
till  complete  awakening  has  taken  place.  In  the  recent  vol- 
ume of  Billroth's  'Deutsche  Chirurgie,' which  is  devoted  en- 
tirely to  anaesthetics.  Dr.  Kappeler,  from  an  experience  of 
twenty-five  cases,  speaks  strongly  against  the  practice  of  mixed 
anaesthesia  by  morphia  and  ether,  but  allows  that  by  morphia 
and  chloroform,  to  be  open  to  less  objection.  Whether  death 
occurs  by  the  ether  deepening  the  morphia  narcosis,  or  by  the 
morphism  preventing  the  patient  from  clearing  his  bronchi 
from  the  secretion  provoked  by  the  ether,  I  will  not  undertake 
to  say.  It  appears  to  me,  to  be  a  very  proper  question  for 
physiological  experiment.  Similar  warnings  have  been  ut- 
tered, against  this  form  of  'mixed  anaesthesia;'  but  I  do  not 
think  public  attention  has  before  been  called  to  this  explana- 
tion of  deaths  in  hernia  operation  under  the  use  of  ether." 


498  ARTIFICIAL   AX.lisTHESIA. 

Mixed  Narcosis. 

"  A  mode  of  producing  anopsthesia,  called  mixed  narcosis 
(gemischte  narhose),  has  been  employed  by  Thiersch,  of  Leipzig, 
whereby  insensibility  to  pain,  may  be  procured  without  the 
total  abolition  of  consciousness.  The  credit  of  the  discovery 
is  ascribed  to  Prof.  Nussbaum,  of  Munich.  Although  suitable  for 
all  kinds  of  operations,  it  is  especially  serviceable  for  operations 
about  the  mouth  and  jaws,  in  which  blood  is  apt  to  flow  into 
the  trachea,  or  down  the  oesophagus  into  the  stomach,  and  sub- 
sequently to  cause  vomiting.  In  some  cases,  of  the  removal  of 
the  upper  jaw,  lately  performed  by  Thiersch,  the  patient  allowed 
the  blood  to  accumulate  for  a  while  at  the  back  of  the  pharynx, 
and  then  spat  it  completely  out  when  asked  to  do  so ;  and  we 
are  informed  that  in  one  instance,  the  patient  watched  with 
evident  interest  the  motion  of  the  saw  that  was  dividing  his 
upper  jaw-bone. 

"A  subcutaneous  injection  of  morphia,  from  a  quarter  to  half 
a  grain,  is  given  as  soon  as  the  patient  is  placed  upon  the  oper- 
ating-table, and  immediately  afterward,  the  administration  of 
chloroform  is  commenced.  After  inhalation  for  about  five 
minutes,  the  operation  may  usually  be  begun,  but  the  chloro- 
form must  be  renewed  at  intervals.  The  patients  lose  all  sen- 
sibility to  pain,  but  evidently  retain  a  considerable  degree  of 
consciousness,  and  control  of  voluntary  movements.  Within  the 
last  month,  mixed  narcosis  has  been  employed  five  times  suc- 
cessfully, as  far  as  the  annihilation  of  pain  is  concerned,  and 
without  any  bad  effects." — London  Lancet. 

The  dose  of  morphia,  which  is  given  in  the  communication 
in  the  Lancet,  is  too  large  for  safety,  as  there  are  many  persona 
on  whom  even  one-quarter  of  a  grain  of  morphia,  hypodermic- 
ally,  will  act  as  a  powerful  poison,  while  half  a  grain  might 
cause  death.  The  dose  of  morphia  by  injection  under  the 
skin — not  in  the  vein — should  not  be  more  than  gr.  \  to  J  given 
hypoderraiciilly  half  an  hour  before  employing  the  chloroform. 
The  objections  to  it  are,  that  it  may  produce  great  excitement, 
and  vomiting.  "  Pouncet,''^  Jrom  a  wide  experience  during  the 
Franco- Prussian  War ,  abandoned  the  method,  owing  to  the  fre- 
quency of  prolonged  stupor,  which  followed  its  use. 


ALBUMEN   IN   UKINE,  DANGEROUS.  499 

Presence  of  Albumen  in  tlie  Urine,  after  the  Ad- 
ministration of   Cliloroform. 

MM.  Ferrier,  and  Patiu,  have  experimented  upon  the  pro- 
duction of  albumen  in  the  urine,  by  the  administration  of  chlo- 
roform. Ten  experiments  in  all  were  performed,  and  the  urine 
in  each,  was  tested  b'efare,  and  after,  the  operation. 

In  six  cases  out  of  nine,  albumen  was  found  after,  though  not 
before,  chloroformization.  In  the  tenth,  the  quantity  of  albu- 
men was  increased  from  nine  grains  per  quart — before  anaes- 
thesia— to  sixty  grains  afterward.     This  patient  died. 

In  resume,  anaesthesia  by  chloroform,  is  frequently,  but  not 
fatally,  followed  by  albuminuria,  thus  confirming  the  experi- 
ments of  Bouchard,  who  has  observed  albumen  in  the  urine  of 
liares,  after  peripheral  nervous  lesion,  and  after  the  inhalation 
of  chloroform — even  without  production  of  angesthesia.  Under 
the  last  condition,  haematuria  has  also  been  observed.  M. 
Ferrier,  is  inclined  to  attribute  the  albuminuria  to  a  certain 
tendency  to  asphyxia  produced  by  chloroform. — Revue  de  Chi- 
rurgie,  Jan.,  1885  ;  Medical  News,  April  11,  '%5. 

According  to  Dr.  Baillee,  there  is  no  more  energetic  means 
of  overcoming  the  narcosis  produced  by  chloroform,  than  the 
iutroducfcioH  of  a  small  piece  of  ice,  into  the  rectum.  It  can  be 
pushed  through  the  sphincter,  without  the  employment  of  much 
force-  It  immediately  melts,  producing  a  deep  inspiration, 
which  is  the  precursor  of  natural  respiration,  and  the  re-estab- 
lishment of  cardiac  functions. 

The  Influence  of  Ifitrite  of  Amyl,  in  Counteracting- 

the  Depressing-  Effects  of  Ether,  Chloroform, 

and  Cocaine,  Dviring  Anaesthesia. 

In  nitrite  of  amyl,  we  have  an  agent  which  produces  a  marked 
dilatation  of  the  superficial  vessels,  and  must,  therefore,  to  a 
corresponding,  degree,  relieve  the  congestion  of  the  visceral 
circulation  by  lessening  the  tension  of  the  blood;  but  it  must 
never  be  used,  when  there  is  a  flushed  face,  and  congested  ves- 
sels.   If  the  patient  is  able  to  inhale,  hold  a  bottle  of  it  under 


500  ARTIFICIAL   ANAESTHESIA. 

the  nostrils,  and  direct  him  to  sniff  it  up  freely,  and  repeat  this 
frequently.  If  not  strong  enough  to  inhale,  let  a  small  elastic 
bag  be  filled  with  the  vapor  ;  force  the  vapor  into  the  nostrils 
at  intervals,  using  artificial  respiration.  To  such  an  extent  will 
this  agent  relax  muscular  spasm,  that  it  has  at  times  overcome 
the  tetanic  spasm  caused  by  strychnine,  and  relieves  the  most 
agonizing  of  known  maladies,  angina  pectoris.  Even  tetanus 
has  been  alleviated  by  its  prompt  use.  In  certain  forms  of 
asthma,  it  will  relieve  the  spasm  and  arrest  the  paroxysm,  but 
when  associated  with  or  dependent  upon  chronic  bronchi- 
tis, and  emphysema,  it  is  not  advisable  to  use  it,  nor  in  aortic 
disease. 

An  exceedingly  convenient  mode  of  carrying  the  drug,  is  by 
means  of  thin  glass  globules,  containing  respectively  Tl\iissand 
tl^v.  When  required,  one  of  the  bulbs  is  broken  in  a  handker- 
chief or  towel,  and  its  contents  immediately  inhaled.  It  is 
found  valuable  as  inhalation,  at  the  commencement  of  the  aura 
of  epilepsy,  to  be  followed  by  the  use  of  the  bromides  of  potas- 
sium, sodium,  lithium  and  iron  ;  subsequently,  by  the  use  of 
arsenic.  Sometimes  inhalation  of  the  dru^  causes  in  certain 
individuals  disagreeable  dizziness ;  also  sudden  collapse  has  fol- 
lowed its  too  free  use. 

"  SchuUer's"  experiments,  showed  a  marked  contraction  of 
the  vessels  of  the  pia  mater,  followed  by  the  usual  dilatation. 
It  has  also  been  observed,  that  certain  patients  state,  that  objects 
appeared  of  a  yellow  color,  subsequent  to  the  use  of  the 
nitrite. 

Impurities. — If  exposed  to  the  air  it  decomposes,  leaving 
amyl  alcohol.  It  is  apt  to  contain  free*acid,  nitrate  of  amyl, 
and  nitropentone.  It  should  be  re-distilled  and  purified  before 
use. 

There  is  a  very  great  difference  in  the  effects  which  nitrite 
of  amyl,  chemically  pure,  produces  in  different  persons.  We 
know  of  two  person-i,  who  cannot  approach  it  without  immedi- 
ately experiencing  a  feeling  of  distress  in  the  region  of  the 
heart,  accompanied  by  a  sense  of  faintnes3.  Another,  after  one 
whiff,  swung  around,  and  would  have  fallen  to  the  ground,  if 
support  had  not  been  at  hand.    In  our  own  case,  we  can  inhale 


EMPLOYMENT   OF   NITRITE   OF   AMYL.  501 

it  with  impunity,  and  it  requires  five  to  ten  seconds  before 
flusliing  of  the  face,  disturbance  of  the  heart,  or  giddiness  are 
induced. 

When  first  employed,  it  was  with  the  greatest  amount  of  care ; 
it  was  supposed  to  be  very  dangerous,  but  we  have  not  found 
it  to  be  so,  nor  have  we  as  yet  known,  of  a  single  de.ith  from  it, 
when  used  as  a  therapeutic  agent. 

In  a  case  of  spasm  of  the  glottis,  following  pneumonia,  we 
employed  inhalations  of  the  nitrite  of  amyl,  in  the  form  of  the 
glass  globules,  "  pearls  of  nitrite  of  amyl,"  with  success,  much 
to  the  relief  of  the  patient. 

While  traveling  during  the  summer  of  1877,  we  met  a  well- 
known  gentleman  of  Philadelphia,  the  late  Mr.  E.  Bonsell,* 
who  was  affected  with  angina  pectoris.  A  vial  of  nitrite  of 
amyl  was  his  constant  companion,  for  several  years.  Every  lit- 
tle while,  he  would  inhale  its  vapor  with  decided  benefit  and 
relief.  He  had  done  so  for  many  months,  without  the  least 
deleterious  efiect. 

In  another  case  this  remedy  completely  failed,  and  hypoder- 
mic injections  of  morphia  had  to  be  resorted  to  during  the 
attacks. 

In  most  cases  it  is  best  administered  lying  down.  Women 
are  more  susceptible  to  its  effects,  than  men.  Given  internally, 
with  mucilage  and  an  aromatic,  it  will  at  times  produce 
nausea;  generally  an  irritation  of  the  throat.  This  is  increased 
by  the  impurity  of  the  drug. 

Taking  into  consideration  the  different  idiosyncrasies  and 
susceptibilities,  it  is  better  in  all  cases  to  begin  with  the  mini- 
mum dose,  say  one  drop,  and  gradually  increase,  if  well  toler- 
ated. It  should  never  be  trusted  to  the  patient,  until  its  effects 
upon  his  system  are  well  known. 

In  "flushings  of  heat,"  or  "heats,"'  which  so  frequently 
trouble  women  at  the  change  of  life,  or  caused  occasionally  by 
the  sudden  arrest  of  menstruation,  the  action  of  nitrite  of  amyl, 
followed  by  tincture  of  aconite,  one  drop  in  water,  every  half-hour 
until  the  pulse  has  begun  to  be  affected,  and  then  every  hour 
or  two  hours,  according  to  the  necessities  of  the  case,  according 

*  He  died  at  the  advanced  age  of  eighty -two,  during  1879. 


502  ARTIFICIAL   ANESTHESIA. 

to  Ringer,  is  very  marked,  preventing  or  greatly  diminishing 
the  profuse  perspiration  and  consequent  prostration.  It  is  said 
to  be  useful  in  sick  headache  and  in  preventing  sea-sickness. 
It  is  stated  to  have  arrested  a  paroxysm  of  intermittent  fever, 
when  inhaled  during  the  cold  stage  in  the  dose  of  four  drops. 
We  have  made  a  series  of  experiments  with  this  remedy,  in 
tinnitus  aurium,  and  came  to  the  conclusion  that  it  was  es- 
pecially suggested  only  in  affections  of  the  labyrinth.  We  were 
led  to  employ  this  remedy  from  its  well-known  sedative  action 
upon  the  sympathetic  system,  especially  the  vaso-motor  nerves, 
and  the  fact  that  many  forms  of  tinnitus  are  caused  not  only 
by  an  increased  intra-labyrinthine  pressure,  but  occur  as  the 
result  of  nervous  irritation,  not  only  of  the  auditory  nerve,  but 
in  branches  of  the  fifih,  of  a  neuralgic  character  or  trophic 
type  of  changes.  The  remedy  was  employed  by  Dr.  Michel  in 
twenty-five  cases  by  himself,  and  in  six  cases  by  Dr.  Urbant- 
chitsch.  More  or  less  improvement  occurred  in  nineteen  cases ; 
among  these  were  three  in  which  the  tinnitus  disappeared  en- 
tirely from  one  ear,  and  in  another  case  was  somewhat  dimin- 
ished. From  one  to  five  drops  of  the  remedy  were  inhaled  at  a 
sitting.  The  inhalation  was  continued  during  the  appearance 
of  the  usual  symptoms — flushing  of  the  face,  injection  of  the 
blood-vessels  of  the  eye,  etc.,  and  suspended  on  the  occurrence 
of  vertigo.  In  all,  the  cases  improved;  the  tinnitus  was  in- 
creased durwg  the  period  of  inhalation. 

At  times,  we  have  been  much  disappointed  in  the  effects  of 
nitrite  of  amyl,  owing  to  its  being  impure,  having  found  it  to  be 
nothing  more  than  amylic  ether,  and  requiring  redistillation. 
The  amyl,  is  an  agent  which  should  always  be  in  the  armamen- 
tarium of  the  medical  man,  who  is  prepared  to  meet  any  emer- 
gency that  might  arise,  while  producing  anaesthesia  with  chlo- 
roform, ether,  or  cocaine, 

Hji>notisin  as  an  Anaesthetic. 

Hypnotism  (from  hypnoa)  is  the  production  of  sleep,  by  what 
was  generally  known  as  animal  magnetism.  Only  certain  in- 
dividuals are  susceptible  to  its  influence.  The  person  who 
operates  has,  in  our  opinion,  great  will  power  over  the  individ- 


HYPNOTISM.  503 

ual  operated  upon.  The  patient  hypnotized,  is  not  absolutely- 
insensible,  but  operations  of  a  trifling  nature  can  be  performed 
without  apparent  pain. 

Therapeutic  Hypnotism. 

"  It  is  quite  well  known  that  a  course  of  action  suggested  to 
a  hypnotized  person  is  followed  irresistibly  and  unconsciously 
by  that  person  after,  as  well  as  during,  the  hypnotic  state. 
Upon  this  is  based  the  medical  application  of  hypnotism.  If 
a  subject  can  be  made  to  carry  out  useless,  eccentric,  or,  in 
some  cases  that  have  become  known,  even  criminal  suggestions, 
without  his  own  knowledge  of  the  character  or  the  cause  of 
.his  action,  why,  ask  the  scientific  experimenters,  may  not  the 
same  cerebral  mechanism  be  brought  into  play  to  influence  the 
physical  state  of  persons  suffering  from  certain  kinds  of  dis- 
orders? The  influence  of  the  mind  and  the  imaginative 
faculties  on  the  body  in  such  cases  has  long  been  known  ;  and 
it  is  maintained  that  this  kind  of  suggestion  does  not  differ, 
in  reality  from  that  of  the  hypnotic  state.  Whatever  may  be 
the  cause  which  incites  the  nervous  centres  of  the  brain  to  in- 
tervene in  order  usefully  to  modify  the  organic  functions  of  the 
body,  the  process,  say  these  investigators,  is  the  same. 

"  According  to  the  reports  submitted  at  the  late  Congress, 
the  treatment  of  invalids  in  this  manner  already  shows  some 
remarkable  results.  Two  physicians  of  Amsterdam  told  of 
414  cases  they  had  treated  by  hypnotism.  Of  these  100  were 
fully  cured,  in  98  there  was  a  noticeable  improvement,  in  92 
a  slight  one,  and  in  only  71  were  there  no  results;  58  cases 
were  not  followed.  These  cases  included  organic  maladies  of 
the  nervous  system,  mental  diseases,  and  neuralgia,  besides 
others  not  directly  connected  with  the  nervous  system.  The 
treatment  of  the  insane  was  especially  discussed  by  others,  and 
here,  too,  success  has  been  obtained  in  some  cases,  though  the 
difficulties  are  far  greater  than  in  physical  maladies.  A  curi- 
ous and  interesting  report  was  presented  by  one  of  the  physi- 
cians in  regard  to  his  experiments  with  children,  whom  he 
found  easier  to  influence  by  suggestion  than  their  elders.  In 
this  he  submitted  as  a  proved  conclusion  the  value  of  hypnotic 


504  ARTIFICIAL  ANESTHESIA. 

suggestion  as  *an  excellent  auxiliary  in  the  education  of 
vicious  or  degenerate  children,'  it  being  'especially  efficient 
in  reacting  against  vicious  instincts,  habitual  lying,  cruelty, 
theft,  and  inveterate  idleness.'  This  is,  perhaps,  one  of  the 
most  startling  assurances  we  are  given  of  the  powers  of  hyp- 
notism in  the  hands  of  competent  men  ;  and  such  results, 
already  attained,  seem  to  point  to  possibilities  of  great  import- 
ance in  the  farther  development  of  this  study. 

"  There  is  another  side  to  all  this,  however,  which  the  Con- 
gress in  Paris  did  not  fail  to  consider.  That  is  the  danger  of 
the  abuse  and  the  irresponsible  use  of  the  hypnotic  phenomena. 
Trick  performances  of  travelling  quacks  are  common,  even  in 
this  country  ;  and  they  are  to  be  considered  not  only  as  a 
vulgarization  of  the  science,  but  a  danger  to  health  and  morals. 
Equal  danger  rests  in  the  experiments  of  the  well-meaning  but 
unskilled ;  while  the  opportunities  that  hypnotism  atTords  the 
criminally  inclined,  it  can  easily  be  seen,  are  numerous.  A 
hypnotized  subject  is  readily  made  the  instrument  of  vengeance 
or  cupidity,  quite  unconsciously  to  himself,  after  emerging  from 
the  hypnotic  state ;  and  not  only  that,  but  may  be  made  to  take 
upon  himself  the  sole  blame.  All  these  perils,  it  may  be,  will 
some  time  have  to  be  guarded  against,  though  knowledge  of 
the  subject  is  yet  too  restricted  to  make  them  alarming.  But 
if  this  be  so,  it  will  be  only  one  more  instance,  so  many  of  which 
modern  times  can  show,  in  which  things  of  value  to  humanity 
are  perverted  to  damaging  uses.  Of  course  this  unfortunate 
fact  will  not  put  an  end  to  the  investigations  which  promise  so 
much  of  value ;  the  advances  made  in  this  curious  and,  in  its 
scientific  application,  so  recent  branch  of  scientific  study  will 
be  watched  with  great  interest."  * 

Hypnotics  or  Soporifics. 

Most  of  the  soporifics,  or  hypnotics,  stimulate  the  mental 
functions,  when  given  in  very  small  doses  ;  in  increased  doses 
they  diminish  or  abolish  the  mental  faculties.  The  same  drug 
— as,  for  example,  opium,  or  alcohol,  in  different  doses  may  act 
as  a  stimulant,  narcotic  and  anaesthetic. 

*  Providet)ce  Journal,  September,  18S9. 


HYPNOTICS.  505 

The  chief  hypnotics  are : 

Opium  Bromide  of  potassium 

Morphine  Bromide  of  sodium 

Chloral  hydrate  Bromide  of  calcium 

Butyl-chloral-hydrate  Bromide  of  zinc 

Croton  chloral  Monobromo-camphor 

Hyoscyamus  ^              Hop 

Cannabis  Lettuce 

Paraldehyde  Lactic  acid 

These  general  anaesthetics,  which  are  chiefly  employed  at  the 
present  day  in  the  practice  of  medicine,  may  be  reduced  in 
number  to  four:  alcohols,  ethers,  chloroform,  and  nitrous  oxide 
gas.  These  are  employed  alone,  or  mixed  in  various  propor- 
tions. They  can  be  reduced  to  a  still  smaller  number,  viz. : 
nitrous  oxide  gas,  and  alcohol,  as  each  of  the  eleven  alcohols, 
will,  by  the  chemical  action  of  an  acid,  produce  its  ether  or 
chloroform. 

General  anaesthetics  are : 

Nitrous  oxide  Terchlorhydrin 

Ether  Bi-chloride  of  methylene 

Chloroform  Paraldehyde 

Bromoform  Bi-chloride  of  ethidene 

Tetrachloride  of  carbon  Bromide  of  ethyl 

Nitrous  oxide  was  the  first  anaesthetic  discovered,  and  is 
still  the  safest  for  all  short  operations,  but  the  most  difficult  to 
administer  really  well.  To  get  its  full  effect,  it  should  be  ad- 
ministered pure,  all  air  being  rigidly  excluded ;  deep  snoring 
and  an  insensitive  conjunctiva  are  the  best  signs  of  insensi- 
bility. Pregnant  and  nursing  women  take  gas  without  any 
deleterious  consequences ;  children,  even  those  who  suffered 
from  chorea  or  epilepsy,  do  not  take  it  well ;  great  age  is  no  dis- 
advantage. From  experiments  by  the  writer  made  on  him- 
self he  had  learned  that  just  before  the  loss  and  return  of  con- 
sciousness, the  hearing  power  was  greatly  intensified,  and  he 
warned  surgeons  to  be  careful  in  their  remarks,  and  advised 
the  room  to  be  kept  as  quiet  as  possible. 
22 


506  ARTIFICIAL  ANiESTHESIA. 

We  have  described  it  as  the  first  systemic  anaesthetic  on  our 
list, 

A  New  Method  for  Producing  Anaesthesia. 

About  three  years  since,  M.  Brown-Sequard  announced  that 
he  had  discovered  a  new  method  of  producing  anaesthesia,  and 
that  under  the  influence  of  an  irritation  of  the  mucous  mem- 
brance  of  the  larynx,  sensibility  to  pain  disappeared  more  or 
less  completely,  in  all  parts  of  the  body.  This  result  he  attrib- 
uted, to  an  inhibitory  influence  exercised  by  the  superior  laryn- 
geal nerves  upon  the  nerve-centres.  He  has  since  continued 
his  experiments  upon  monkeys,  and  upon  himself,  and  has 
recently  reported  his  results  to  the  Academy  of  Sciences.  He 
states  that  he  has  found  carbonic  acid,  and  the  vapor  of  chloro- 
form, to  be  the  most  powerful  agents  for  producing  the  neces- 
sary irritation  of  the  larynx,  but  this  is  dependent  upon  these 
substances,  not  entering  the  lungs,  since  they  thence  pass  into 
the  blood,  and  prevent  the  laryngeal  nerves  from  producing 
analgesia,  without  sleep.  Considerable  difficulty,  however,  was 
experienced  in  applying  either  of  these  agents  to  human  beings, 
and  only  a  partial  success  was  obtained,  by  effecting  the  inhala- 
tion of  pure  air  during  two-thirds,  or  three-fourths,  of  each  res- 
piration, and  then  finishing  the  inhalation  with  carbonic  acid, 
which  had  to  be  expelled  immediately.  Although  an  analgesic 
effect  was  sometimes  manifested  rapidly,  it  was  occasionally 
necessary  to  continue  the  inhalation  of  carbonic  acid  gas  in 
this  way,  during  twenty  minutes  or  more.  It  was  found,  how- 
ever, thus  possible,  without  causing  sleep,  or  interfering  in  any 
degree,  with  the  mental  powers  or  voluntary  movements,  to 
produce  a  nearly-complete  analgesia  of  the  skin,  continuing 
nearly  forty  hours,  a  cessation  during  two  days  of  pains  from 
various  causes,  and  the  complete  disappearance  of  any  excessive 
feeling  of  fatigue,  under  which  the  patient  might  be  suffering 
before  the  administration  of  the  gas.  In  the  case  of  monkeys, 
where  the  irritation  could  be  more  effectually  applied,  it  was 
evident  that  analgesia  could  be  produced,  securing  without 
sleep,  insensibility,  in  respect  to  wounds^  lasting  ten  days  or 
even  longer. 


INSANITY  FOLLOWING  USE  OF  ANESTHETICS.     507 


Insanity  Following  the  Use  of  Anaesthetics  in 
Operations. 

Dr.  George  H.  Savage,  one  of  the  most  distinguished  and 
capable  physicians  who  has  the  opportunity,  as  Superintendent 
and  Resident  Physician,  of  the  Bethlehem  Eoyal  Hospital,  of 
London,  of  seeing  a  large  number  of  acute  cases  of  insanity, 
has  called  the  attention  of  the  profession  in  a  paper  on  this 
subject  read  before  the  British  Medical  Association,  held  in 
Dublin,  August,  1887  [British  Medical  Association  Journal, 
Dec.  3,  '87).  He  had  met  with  a  series  of  cases  in  which  the 
use  of  anaesthetics,  in  predisposed  subjects,  has  been  followed 
by  insanity.  To  make  the  matter  more  clear,  he  has  also  col- 
lected similar  cases  which  have  followed  similar  causes,  such 
as  the  use  of  alcohol,  belladonna,  etc.  He  thinks,  by  this 
means,  to  be  able  to  show,  that  the  relationship  is  truly  causal. 
He  also  places  before  us  several  propositions  which  he  en- 
deavors to  prove. 

Any  cause  which  gives  rise  to  delirium,  may  set  up  a  more 
chronic  form  of  mental  disorder,  quite  apart  from  any  febrile 
disturbance,  [a]  The  most  common  form  of  mental  disorder, 
which  comes  on  in  such  cases  is  of  the  type  of  acute  delirious 
mania;  (6)  though  such  mental  disorder  is  generally  of  a 
temporary  character,  it  may  pass  into  chronic  weak-minded- 
ness, or  into  (c)  progressive  dementia,  which  cannot  be  dis- 
tinguished from  general  paralysis  of  the  insane.  Beside  alco- 
holic delirium  he  calls  attention  to  the  fact,  that  delirium  ac- 
companying fevers,  may  start  a  similar  set  of  symptoms,  as  also 
pneumonia  in  nervous  patients. 

We  must  not,  however,  forget  that  shock  after  an  operation 
of  any  kind,  may  produce  similar  mental  disorder.  We  would 
refer  our  readers  to  the  report  of  the  cases  in  detail,  and  con- 
clude with  the  practical  deduction  of  the  writer,  as  follows : 
In  this  paper  he  has  combined  the  experience  of  many  years. 
One  or  two  practical  questions  arise  for  the  surgeon,  the  most 
important  being  whether  neurotic  inheritance  or  neurosis  in 
the  individual,  as  proved  by  a  previous  attack  of  insanity,  should 


508  ARTIFICIAL  AN.;ESTHESIA. 

in  any  way  affect  the  prognosis  in  operations,  and  to  what 
degree  should  it  interfere  with  operations  of  convenience,  not 
essential  for  the  prolonging  or  saving  of  life. 

Ether  or  Chloroforai— Wliicli  ?* 

"  The  important  question  as  to  the  choice  of  an  anaesthetic,  is 
by  no  means  the  simple  affair  which  the  partisansof  one,  or  the 
other  claim  it  to  be.  Recent  discussions  on  this  subject,  in 
the  British  Medical  Association,  in  the  Academy  of  Medicine, 
in  New  York,  and  in  the  County  Medical  Society,  in  Brooklyn, 
together  with  many  editorial,  and  other  contributions,  in  various 
medical  journals,  have  served  to  call  attention  to  the  various 
phases  of  this  subject.  Perhaps  the  most  important  of  all  the 
lessons  to  be  derived  from  the  facts  which  have  been  elicited, 
is  the  entire  unreliability  of  the  statistical  comparisons  which 
have  heretofore  been  relied  upon,  to  demonstrate  the  relative 
safety  of  the  two  great  anaesthetics — ether  and  chloroform.  It 
seems  to  have  been  quite  clearly  brought  out,  that  while,  as  re- 
gards the  immediate  results  from  its  administration,  chloro- 
form has  rolled  up  a  death  rate  far  in  excess  of  that  produced 
by  ether,  still  the  latter  is  chargeable  with  many  deaths,  from 
later  complications,  determined  by  it,  which  are  as  yet  an 
unknown  quantity,  though  they  are  now,  becoming  more  ap- 
preciated. 

"Shock,  defective  and  delayed  reaction,  heart- failure,  pneu- 
monia, pulmonary  oedema,  uraemia,  nephritis,  are  terms  which 
in  many  instances  have  explained  deaths  which  were  properly 
attributable  to  ether.  The  appreciation  of  these  facts,  must 
lead  to  a  more  careful  study  of  the  whole  subject  of  anaesthe- 
sia, and  to  greater  attention  to  its  technique  by  practitioners 
in  general.  As  a  contribution  to  this  subject.  Dr.  A.  B.  Miles, 
of  New  Orleans,  presented  a  memoir  to  the  Orleans  Parish 
Medical  Society,  June  27,  1887,  which  has  been  published  in 
the  August  issue,  of  the  New  Orleans  Medical  and  Surgical 
Jovrnal.  In  this  memoir,  the  relative  merits  and  demerits  of 
ether  and  chloroform,  together  with  the  conditions  of  the  body 

*  "Annals  of  Surgery,"  Oct.,  1887,  p.  327. 


ETHER   OR   CHLOROFORM — WHICH  ?  509 

which  may  influence  their  effects  when  administered  for  anses- 
thesia,  are  presented,  and  discussed,  with  great  discrimination 
and  clearness.  With  this  preface,  we  reproduce  the  greater 
part  of  it,  which  will  be  found  to  be  worthy  of  careful  study  : 

"Ether  is  the  weaker  ansestbetic,  possessing  the  peculiar 
toxical  quality  in  less  degree  than  chloroform.  In  small  quan- 
tity it  is  decidedly  stimulating  to  the  cerebrum  and  to  the 
vital  functions  over  which  the  medulla  presides  ;  and,  in  this 
action,  it  is  more  uniform  than  chloroform.  Indeed,  the  vital 
reflexes  are  so  uniformly  stimulated  by  ether,  that  the  danger 
of  its  primary  effects  in  healthy  subjects,  is  as  small  as  possible 
under  general  ansesthesia.  In  those  who  take  ether  well,  the 
stimulating  effect  on  the  heart's  action  and  respiration  may  be 
observed  throughout  the  ansesthesia.  Ordinarily,  even  anges- 
thetic  doses  of  ether  do  not  depress  these  functions,  but  leave 
them  to  themselves,  uninfluenced  by  the  general  anaesthetic 
action.  Under  etherization,  the  heart's  action  and  respiration 
are  certainly  less  liable  to  the  irregularities,  which  are  not  un- 
frequently  observed  in  chloroform  anaesthesia.  In  the  latter 
stages  of  etherization,  however,  the  vital  reflexes  may  be  de- 
pressed, and  powerfully,  but  gradually,  so  as  to  give  warning 
of  the  approach  of  danger.  Ether  danger,  usually  approaches 
by  way  of  the  lungs,  and  usually  forewarns  by  the  labored, 
stertorous,  irregular  breathing,  and  cyanosis,  so  as  to  allow  the 
use  of  means  to  avert.  Ether  danger  may,  however,  approach  by 
the  heart.  In  ten  of  forty,  well  authenticated  ether  deaths,  the 
heart  failed  first.  These  deaths  resemble  chloroform  deaths, 
but  comparatively  occur  much  less  frequently.  So  the  com- 
parative safety  of  ether,  and  its  timely  admonition  of  danger, 
are  its  chief  advantages.  They  are  certainly  points  of  great 
practical  value,  in  its  favor. 

"  Against  the  merits  of  ether,  stand  in  stronger  relief  to-day 
than  ever  before  its  disadvantages  and  its  dangers.  The  advo- 
cates of  ether,  who  use  it  excessively,  especially  those  who  yet 
believe  in  its  absolute  safety,  are  doing  much  to-day  to  demon- 
strate its  dangers.  Its  inflammability  in  the  presence  of  artifi- 
cial light,  and  the  actual  cauteries,  is  one  objection.  The 
danger  of   igniting  is   modified  by  several    conditions :  the 


510  ARTIFICIAL   ANAESTHESIA. 

proximity  of  the  light,  its  position,  and  whether  exposed  or 
not,  the  saturation  of  the  surrounding  air  and  the  direction  of 
the  air  currents.  Ether  may  ignite  at  long  distances  (fifteen 
feet,  it  is  said)  if  the  currents  set  in  the  direction  of  an  ex- 
posed light.  But  the  dangers  of  inflammability  may  be  mod- 
ified, as  above  indicated,  and  much  diminished.  The  exceed- 
ingly disagreeable  odor,  and  the  irritating  property  of  ether, 
when  brought  in  contact  with  mucous  surfaces,  are  serious  dis- 
advantages. It  was  this  irritating  property,  which  refuted  the 
claims  of  rectal  etherization  as  a  warrantable  procedure  in 
surgery,  but  not  until  it  had  brought  sorrow  on  its  advocates, 
and  a  worse  fate  on  some  of  its  victims — diarrhcea,  dysentery, 
hemorrhage,  collapse,  death.  The  irritation  of  the  respiratory 
mucous  membrane,  usually  causes  coughing,  strangling  and 
violent  resistance.  It  may  cause  catarrhal  bronchitis,  and 
pneumonia.  It  may  very  seriously  aggravate  a  pre-existing 
bronchial  or  parenchymatous  inflammation. 

"The  excessive  secretion  which  ether  causes  to  flow  into  the 
breathing  passages,  is  also  a  disadvantage  not  to  be  lightly 
regarded.  This  may  endanger  life  by  suffocation,  especially 
in  cases  of  pulmonary  disease,  already  attended  with  free 
secretion,  as  in  the  catarrhal  affections  of  children,  and  old 
people.  It  not  unfrequently  prolongs  the  asphyxia  caused  by 
the  usual  method  of  administering  ether. 

"  Patients  are  usually  asphyxiated,  while  being  anaesthetized 
with  ether.  True,  the  asphyxia  favors  the  ana3sthetic  effect  of 
ether,  and  therefore  obviates  the  necessity  of  too  greatly  sat- 
urating the  blood.  But  the  asphyxia  complicates  and  in- 
creases the  danger  of  anjesthesia.  The  dangers  of  such  a  state 
are  beyond  question.  They  are  not  so  immediate  as  those  of 
chloroform,  and,  therefore,  have  been  less  apparent,  and  lesa 
appreciated. 

"  Asphyxia,  as  well  as  etherization,  may  be  carried  too  far, 
and  at  times  result  disastrously.  The  respiratory  nervous  ap- 
paratus is  exhausted,  and  the  heart  fails  secondarily.  The 
tone  of  its  own  texture  is  destroyed,  by  the  supply  of  venous 
blood,  and  by  impediment  to  the  pulmonary  circulation,  its 
right   ventricle  becomes  overdistended,  and  powerless.      So, 


ETHER   OR   CHLOROFORM?  51 1 

etherization,  as  much  from  asphyxia,  due  to  the  manner  of 
administration,  as  from  its  anaesthetic  effect,  may  depress  the 
heart's  action,  as  well  as  respiration.  But  the  sequelaj  of 
etherization,  are  matters  of  more  serious  importance,  to  which 
attention  is  specially  directed. 

"Aside  from  the  danger  of  inflammatory  diseases,  caused  by 
the  irritating  ether  vapor,  is  the  liability  to  pneumonia,  as  the 
result  of  obstructed  pulmonary  circulation. 

"Again,  the  asphyxia  which  goes  along  with  etherization, 
may  increase  the  patient's  depression,  and  retard  reaction. 
The  deleterious  blood  changes  in  a  patient  who  has  under- 
gone prolonged  etherization,  cannot  be  well  suited  to  the  heal- 
ing of  important  wounds.  In  the  suffocating  plan  of  adminis- 
tering ether  the  blood  suffers  not  alone  of  the  interruption  to 
the  interchange  of  gases,  but  as  much  of  the  rebreathing  of 
excrementitious  albuminoid  products,  which  physiologists  tell 
us  are  so  harmful. 

"  The  danger  of  nephritis,  by  the  action  of  blood  saturated 
with  ether,  first  pointed  out  by  Dr.  Emmet,  of  New  York,  has 
been  authentically  confirmed  by  many  observers.  Healthy 
organs  may  be  acutely  inflamed,  and  those  previously  diseased, 
may  be  greatly  aggravated  by  the  passage  of  such  an  irritant 
over  their  secretory  surfaces.  The  danger  to  the  kidneys, 
led  to  the  general  adoption  of  the  method  by  forced  etheriza- 
tion, by  which  the  asphyxia  lessens  the  quantity  of  the  ether 
required. 

"  Ether,  more  frequently  than  chloroform,  causes  nausea  and 
vomiting.  This  is  an  important  consideration,  in  the  selection 
of  an  anaesthetic  to  be  administered  in  cases  in  which  per- 
sistent retching  may  interfere  with  the  healing  of  important 
wounds. 

"  While  the  immediate  dangers  of  ether  are  comparatively 
slight,  those  which  occur  subsequently,  to  which  we  have  just 
alluded,  are  matters  of  very  serious  consequence.  These  dan- 
gers weigh  heavily  against  the  merits  of  this  anaesthetic. 

"  Now,  let  us  pass  in  running  review  the  advantages  and 
dangers  of  chloroform. 

"  Its  non-inflammability  in  the  presence  of  artificial  light, 


512  ARTIFICIAL   AN..ISTHESIA. 

or  tbe  actual  cauteries,  is  au  advantage  which  increases  great- 
ly the  range  of  its  usefulness.  It  is  certainly  the  more  agree- 
able to  patients,  less  irritating  to  the  sensory  nerves  of  the  re- 
spiratory passages  and  the  more  enduring  in  its  anaesthetic 
effect.  It  causes  comparatively  little  increase  of  mucous  secre- 
tion. It  is  easier  of  administration,  and  the  mode  of  adminis- 
tration does  not  entail  any  other  effect,  than  that  of  a  pure  and 
simple  anaesthetic.  Chloroform  is  the  more  energetic  agent, 
possessing  the  inherent  toxical  quality,  in  higher  degree  than 
ether.  This  quality,  however,  does  not  differ  in  character 
from  that  which  ether  possesses. 

"The  primary  effect  of  chloroform,  as  of  ether,  is  stimula- 
ting to  the  cerebrum  and  the  vital  functions ;  but  the  excite- 
ment is  less  intense  and  of  shorter  duration  than  in  etheriza- 
tion. Being  the  more  energetic  agent,  it  requires  less  saturation 
of  the  system,  for  the  exercise  of  its  anaesthetic  power.  This 
is  an  important  consideration.  The  practical  advantages  of 
chloroform  in  surgery,  are  very  striking.  These  and  its  com- 
parative freedom  from  disastrous  sequehe,  take  away  much  of 
the  terror  of  its  immediate  dangers. 

"  The  dangers  of  chloroform  are  soon  told.  They  are  imme- 
diate. If  patients  do  not  die  during  the  administration,  they 
are  comparatively  safe.  Nearly  fifty  per  cent,  of  deaths  by 
chloroform  occur  at  the  outset  of  the  administration.  The 
chief  danger  of  chloroform  is  paralysis  of  the  nervous  appa- 
ratus, governing  circulation,  and  respiration  mentioned  in  the 
order  of  frequency.  The  centres  are  taken  by  surprise  by  the 
direct,  and  energetic  action  of  chloroform,  and  overwhelmed 
quickly.  This  sudden  action  has  given  to  chloroform,  the 
name  of  being  treacherous.  It  teaches  unmistakably  the  ne- 
cessity of  gradually  accustoming  the  centres  to  the  influence 
of  anaesthetics.     AVe  dwell  on  this  point  with  special  emphasis. 

"A  large  proportion  of  deaths  by  chloroform  are  reported  as 
occurring  suddenly,  and  without  warning.  These  cases  are 
usually  reported  in  a  way  to  lay  all  the  blame  on  chloroform. 
While  we  do  not  doubt  the  extreme  susceptibility  of  some  pa- 
tients, which  makes  them  liable  to  such  fatal  accidents,  we  are 
constrained  to  believe  that  in  more  instances  than  recorded, 


ETHER   OR   CHLOROFORM?  513 

there  are  timely  admonitions  of  danger.  These  admonitions 
are  irregularities  of  the  heart's  action,  and  respiration.  Exper- 
iments on  animals,  have  shown  how,  under  chloroform  anaes- 
thesia, the  heart  is  liable  to  sudden  irregularities.  Clinical 
experience  confirms  the  observation.  Irregularity  of  the 
heart's  action,  as  regards  the  strength  of  its  beats,  is  especially 
ominous.  The  hesitating,  irregular  respiration  of  chloroform 
anaesthesia  is  but  little  less  valuable  as  a  warning  of  danger, 
and  certainly  demands  more  attention  than  usually  given. 
The  statistics  before  mentioned,  show,  that  in  one-fourth  of 
forty  cases  of  chloroform  death,  respiration  failed  before  the 
heart's  action.  Patients  who  breathe  irregularly,  should  be 
anaesthetized  with  the  utmost  caution.  These  irregularities  of 
the  heart's  action,  and  respiration,  indicate  a  condition  of  the 
centres  which  bears  anaesthetics  badly.  This  condition  is 
more  frequently  observed  in  the  anaemic  and  weakly,  and  in 
those  under  the  influence  of  depressing  emotions. 

"  The  dangers  of  ether,  and  of  chloroform,  are  modified  by 
methods  of  administration.  Indeed,  we  feel  safe  in  venturing 
the  assertion,  that  the  dangers  of  anaesthesia  lie  not  more  in 
the  inherent  property  of  the  agent  employed,  than  in  the  man- 
ner of  its  administration. 

"The  risks  are  very  much  greater  in  the  unskillful  adminis- 
tration of  chloroform,  than  in  reckless  etherization.  In  view 
of  the  danger  of  its  primary  effect,  we  insist  here  on  the  advi- 
sability of  preparing  the  way  for  chloroform.  Agents  should 
be  given  in  advance  to  stimulate  the  vital  reflexes  and  prepare 
the  nerve  centres  for  the  coming  anaesthetic  effect. 

"The  old-fashioned  whiskey  toddy,  taken  just  before  the 
anaesthetic,  still  has  its  votaries.  The  use  of  alcohol  in  this 
way  is  objectionable.  We  cannot  rely  on  absorption  from  the 
stomach,  at  the  very  time  its  stimulating  action  is  most  desira- 
ble. If  given  immediately  before  the  anaesthetic,  it  is  not  ab- 
sorbed in  time  to  sustain  the  centres  as  they  undergo  primary 
anaesthesia.  If  given  in  time  for  absorption,  the  alcohol  an- 
tagonizes the  action  of  the  anaesthetic.  Alcoholic  patients  are 
difficult  to  anaesthetize,  and  while  under  anaesthesia,  they  often 
show  alarming  symptoms.* 

*  See  article  on  "Alcohol  in  Operationa." 

22* 


514  ARTIFICIAL  ANJ3STHESIA. 

"Again,  alcohol  is  uncertain  in  the  physiological  action  for 
■which  it  is  given.  In  many  subjects,  by  abuse,  perhaps  it 
may  have  long  since  lost  its  medicinal  virtue,  while  in  others 
its  etTect  may  be  variable  because  of  nei'vous  susceptibility. 
Alcohol  taken  into  the  stomach  before  anaesthesia,  has  the  ef- 
fect of  exciting  many  patients  after  a  surgical  operation,  at 
the  time  when  it  is  most  desirable  that  they  should  be  calm. 
This  excitement  may  increase  the  liability  to  inflammation. 
The  maximum  good,  with  the  least  harm,  follows  the  use  of 
alcohol  when  administered  hypodermatically,  or  by  inhalation 
at  the  outset  of  anjesthesia.  The  first  whiffs  of  chloroform 
may  well  be  mixed  with  the  vapor  of  alcohol. 

"A  few  breaths  of  the  vapor  of  ammonia,  in  advance  of  chlo- 
roform, act  like  alcohol,  but  more  potently  and  without  its 
disagreeable  effects. 

"  The  method  of  mixed  anaesthesia,  by  the  hypodermatic  ad- 
ministration of  the  suljjhate  of  morphia  alone,  or  in  combina- 
tion with  a  respiratory  stimulant,  as  the  sulphate  of  atropia, 
is  as  sound  in  physiological  principle  as  useful  in  practice.* 
The  doses  of  the  sulphate  of  morphia  in  adults,  should  not  ex- 
ceed one-twelfth  to  one-sixth  of  a  grain ;  of  the  sulphate  of 
atropia,  one  two-hundredth,  to  one  one-hundred  and  fiftieth 
of  a  grain.  The  atropine  acts  particularly  well  in  states  of 
bronchial  catarrh,  in  pulmonary  diseases  and  in  all  cases  indi- 
cating the  action  of  a  respiratory  stimulant.  The  hypoder- 
matic use  of  morphine,  in  the  doses  recommended,  secures  the 
primary  stimulant  effect  promptly  when  desired,  aids  the 
antesthetic  in  its  action,  and  subsequently  promotes  the  relief 
necessary  after  surgical  procedures. 

"  A  safe  way  of  preparing  the  centres  for  chloroform,  and 
one  which  we  strongly  recommend,  is  by  stimulating  them 
primarily  with  the  inhalation  of  ether.  The  centres  more 
e.^sily  adjust  themselves  to  the  action  of  ether.  Statistics  show, 
that  the  danger  of  the  first  effect  of  ether  is  almost  infinites- 
imal. Thus,  the  anesthesia  is  begun  with  the  agent,  safer  at 
the  beginning,  and  continued  with  the  agent  less  harmful  in 
its  subsequent  effects. 

*  But  not  always  in  practice,  on  account  of  idiosyncrasy  of  patient. 


MODE   OF   USING    CHLOEOFORM.  515 

"  There  are  causes  of  danger  in  the  administration  of  chloro- 
form, which  occur  so  commonly  as  to  warrant  special  mention 
here.  Chief  among  these  common  causes  of  fatal  accidents  is 
overdosage — an  excessive  amount  in  a  given  time.  Patients 
being  anaesthetized  with  chloroform,  should  never  experience 
the  sense  of  suffocation  of  which  we  too  frequently  hear  them 
complain.  Coughing  early  in  the  anaesthesia,  is  usually  an 
evidence  of  over-action.  Chloroform  anaesthesia,  should  be 
begun  with  minimum  doses — a  few  drops  only — and  continued 
to  the  degree  desired  in  quantities  gradually  increasing.  To 
overdosage,  more  than  to  idiosyncrasy  of  patients,  should  be 
attributed  most  of  the  accidents  by  chloroform.  Witness  the 
manner  in  which  so  many  physicians  give  chloroform,  by  satu- 
rating the  inhaler  at  the  outset,  and  forcing  the  anaesthesia,  and 
there  will  be  less  difficulty  in  explaining  many  of  those  deaths, 
that  occur  with  such  electric  suddenness. 

"  Haste  in  the  administration  of  chloroform,  deserves  most 
emphatic  condemnation.  The  anaesthesia  should  be  produced 
gradually,  and  maintained  uniformly.  We  believe  it  unsafe  to 
advise  patients  at  the  beginning  to  '  take  long  breaths,'  with 
the  view  of  quickly  inflating  the  lungs  with  saturated  air,  in 
order  to  produce  a  rapid  effect, 

"  In  the  calm,  which  follows  the  preliminary  excitement, 
chloroform  acts  -with  increased  energy.  The  centres  are  at 
this  moment  in  a  state  of  exhaustion,  and  not  prepared  to 
have  the  anaesthesia  forced.  The  depression  which  follows  the 
primary  excitement,  is  a  period  in  which  much  harm  may  be 
done,  by  overdoses  of  chloroform. 

"  Instead  of  forcing  chloroform  anaesthesia,  at  any  time, 
during  its  administration,  it  is  better  now  and  then,  to  give  the 
patient  a  rest  spell,  in  order  to  refresh  the  residual  air  of  the 
lungs.  Some  of  the  singularly  sudden  deaths,  of  which  we 
read,  may  be  accounted  for  by  the  cumulative  effect  on  the 
centres  caused  by  the  sudden  absorption  of  vapor  which  sat- 
urates the  residual  air. 

"  Statistics  are  yet  wanting  by  which  we  can  accurately  esti- 
mate the  relative  death-rate,  caused  by  ether  and  chloroform. 
At  a  meeting  of  the  New  York  Academy  of  Medicine,  elsewhere 


516  ARTIFICIAL    ANESTHESIA. 

mentioned,  Dr.  Weir  reported  five  deaths  by  ether,  in  10,789 
surgical  operations.  One  surgeon  reported  two  deaths  by 
ether,  occurring  in  his  own  practice,  in  the  course  of  as  many 
months.  These  figures  do  not,  most  probably,  include  deaths 
caused  by  etherization,  yet  occurring  subsequently,  which  in 
years  past  were  not  so  well  understood  as  now.  However,  the 
proceedings  of  the  Academy,  prove  very  convincingly  the 
dangers  of  an  agent,  which  enjoys  an  undeserved  reputation 
for  its  safety. 

"  At  the  same  meeting  of  the  Academy,  Dr.  Knapp,  of  New 
York,  reported  that  from  1860,  to  1876,  he  had  used  chloroform 
in  three  thousand  cases,  without  a  death;  that  since  1870,  he 
had  used  ether  exclusively,  also  without  a  death.  The  last 
death  of  chloroform  in  our  Charity  Hospital,  occurred  on  the 
12th  of  November,  1881 ;  the  subject  a  tertiary  syphilitic  with 
albuminuria,  undergoing  operation  for  removal  of  necrosis  of 
the  tibia.  This  was  one  of  those  appalling,  sudden,  deaths, 
most  of  which  occur  in  patients  who  are  anaemic  and  wasted 
by  chronic  illness.  The  hospital  records  do  not  show  the 
number  of  cases  in  which  general  anaesthetics  have  been  used 
since  1881,  but  give  the  quantity  of  ether  and  chloroform  con- 
sumed, all  of  w'hich,  save  the  small  quantity  used  for  other 
purposes,  was  given  as  a  general  anaesthetic.  In  1881,  eighty- 
eight  pounds  of  chloroform  were  used,  six  of  ether ;  in  1882, 
one  hundred  and  five  of  chloroform,  two  of  ether;  in  1883, 
one  hundred  and  two,  and  eighteen  ;  in  1884,  ninety-four,  and 
fourteen  ;  in  1885,  one  hundred  and  sixteen,  and  twenty-three  ; 
in  1886,  eighty-eight,  and  fifty-six ;  from  January  1  to  June  1, 
1887,  fifty-three  pounds  of  chloroform  and  eighteen  of  ether. 
During  the  five  years,  1882  to  1886,  inclusive,  five  hundred 
and  fifteen  pounds,  or  nearly  fifty  gallons  of  chloroform,  and 
one  hundred  and  thirteen  pounds,  or  a  little  more  than  seven- 
teen gallons  of  ether,  were  used  in  the  hospital.  During  these 
years  85,680  patients  of  all  diseases  have  been  treated,  and,  as 
will  appear  in  the  figures  showing  the  relative  quantity  of 
ether  and  chloroform  used,  the  vast  majority  of  the  patients 
requiring  general  anaesthesia,  including  seven  hundred  cases 
of  important  surgical  operations  reported,  have  been  treated 


ETHER    IN    THE   SURGERY    OF    ADULTS.  517 

with  chloroform.  The  above  statements  are  made  simply  to 
convey  an  approximate  idea  of  the  extent  to  which  chloro- 
form has  been  used  in  this  house,  since  1881,  without  fatal  acci- 
dent.* 

"  It  is  our  conviction,  with  the  lights  before  us,  that  chloro- 
form, carefully  administered,  with  the  precautions  herein 
indicated,  is  as  safe  as  ether  administered  by  the  plan  gener- 
ally practiced  in  America  at  the  present  day.  However,  the 
unskillful  administration  of  chloroform,  and  inattention  to  its 
warnings,  are  fraught  with  so  much  more  danger  than  attends 
or  follows  etherization  by  the  usual  method,  that  we  recom- 
mend ether  in  the  surgery  of  adults  whenever  its  use  is  not  contra- 
indicated. 

*'  Let  us  now  apply  practically,  what  we  have  written,  and 
in  conclusion,  sum  up  those  conditions  indicating,  and  contra- 
indicating,  the  use  of  ether,  and  of  chloroform. 

"  As  a  rule,  in  the  surgery  of  adults,  anaesthesia  should  be 
begun  with  ether,  and  continued  with  ether,  unless  contra- 
indicated.  The  chief  contraindications,  are  pre-existing  in- 
flammation of  the  respiratory  passages,  of  the  lungs  or  the 
kidneys ;  insusceptibility  to  the  eifect  of  ether,  unless  given  in 
overdoses ;  violent  excitement,  which  may  endanger  the  cere- 
bral vessels  in  the  infirm ;  and  local  evidences  of  excessive 
irritation  of  the  respiratory  surfaces. 

"  In  all  quick  operations  which  can  be  performed  during 
primary  angesthesia,  ether  is  especially  preferable.  The  dan- 
ger of  its  primary  effect  is  insignificant. 

"Ether  is  the  more  applicable  in  all  states  of  anaemia,  acute, 
and  chronic ;  and  in  states  of  extreme  nervous  depression, 
whether  caused  by  shock,  fright  or  the  neurasthenia  of  chronic 
disease.  These  are  the  conditions,  in  which  chloroform  deaths 
have  occurred  most  frequently. 

''  Ether  is  especially  preferable  in  cardiac  diseases  and  de- 
generation, where  the  organ  is  weak  in  its  action,  particularly 

*  During  the  Civil  War  Dr.  Hunter  McGuire  collected  the  reports  of  28,000  admin 
istrations  of  chloroform  without  a  death.  Nussbaum  has  recorded  40,000  cases  of 
chloroform  anaesthesia  without  a  death.  These  records  are  very  remarkable.  See 
Discussion  on  McGuire's  paper. 


518  ARTIFICIAL   ANiESTIIESIA. 

in  those  cases  in  which  the  heart's  feebleness  is  manifested  in 
irregularity  as  to  the  strength  of  its  beats.  Such  are  the 
hearts  that  are  exhausted  by  overwork ;  the  dilated  hearts  of 
mitral  and  aortic  regurgitation  ;  the  hearts  which  sympathize 
in  states  of  general  ill-health,  poorly  nourished,  relaxed  in 
tissue,  unsteady  in  action ;  the  hearts  of  those  convalescing  of 
chronic  diseases,  of  patients  depleted  by  exhausting  discharges 
or  hemorrhages,  of  chronic  alcoholics,  of  old  syphilitics  ;  and 
the  hearts  which  have  undergone  degenerative  changes,  re- 
sulting from  disease,  or  the  decay  which  comes  with  age. 

"  Chloroform  is  permissible  in  cardiac  diseases,  attended 
with  overaction  of  the  organ,  as  in  states  of  compensatory 
hypertiophj\  It  is  indicated  in  this  condition  of  the  organ, 
when  associated  with  nephritis.  In  all  diseases  and  deform- 
ities of  the  heart,  whatever  murmurs  may  be  heard,  if  the 
organ  functions  well,  chloroform  may  be  given  if  indicated. 
As  there  are  a  great  many  crippled  limbs  doing  good  service, 
so  there  are  many  hearts,  altered  by  past  diseases,  which  yet 
act  so  well  as  to  give  no  trouble.  Such  hearts  are  apt  to  beat 
more  steadily  under  an  anaesthetic,  than  when  submitted  to  the 
tortures  of  a  painful  surgical  procedure,  without  it. 

"  Chloroform  is  preferable,  whenever  a  general  anagsthetic  is 
required  in  cases  suffering  from  pulmonary  diseases.  It  is  less 
irritating  to  the  respiratory  surfaces,  causes  but  little  increase 
of  the  mucous  secretion,  and  interferes  leas  with  the  pulmon- 
ary circulation.  The  contraindication  to  ether  in  these  cases 
is  very  positive. 

"In  nephritis,  chloroform  is  the  preferable  ana?sthetic.  In 
the  chronic  stage,  ether  is  only  permissible  at  the  beginning  of 
anaesthesia,  to  sustain  the  heart,  now  usually  very  weak,  and 
prepare  the  nerve  centres  for  chloroform.  Of  all  the  condi- 
tions said  to  contraindicate  both  of  these  general  anaesthetics, 
Bright's  diseases  are  entitled  to  the  most  serious  consideration. 
Aside  from  the  asthenic  state  of  heart  muscle,  respiration  is 
very  often  impaired,  either  by  pulmonary  oedema,  or  the  renal 
asthma,  Avhich  results  from  anaemia  of  the  nerve  centres. 
These  conditions  in  the  aggregate,  make  the  use  of  any  anaes- 
thetic of  maximum  danger.     The  observation  of  the  harmful 


CASES    IN    WlllCn    ETHER    IS   APPLICABLE.         519 

effect  on  the  kidneys,  by  blood  charged  with  ether,  has  been 
authentically  confirmed  by  a  number  of  writers,  and  has  con- 
tributed greatly  to  a  better  appreciation  of  the  dangers  of 
ether. 

"Cases are  occasionally  met,  in  which  ether  fails  to  produce 
surgical  ansesthesia,  unless  given  in  an  amount  to  saturate  the 
system  to  a  dangerous  degree.  Such  patients  in  our  observa- 
tion, after  the  preparation  of  the  nervous  system  by  ether,  take 
chloroform  very  happily  and  go  quickly  under  its  influence. 

'*  Chloroform  is  preferable,  then,  in  all  cases  that  take  ether 
badly,  and  those  in  which  the  anaesthetic  power  of  ether  is 
insufficient,  unless  administered  in  overdoses. 

"  Chloroform  is  the  preferable  anaesthetic  in  childhood. 
Statistics  show  that  children,  compared  with  adults,  enjoy  ex- 
ceptional immunity  from  accidents  by  chloroform.  Children 
bear  chloroform  so  well,  that  many  can  be  anaesthetized  during 
sleep;  while,  under  ether,  they  struggle  and  strangle,  and  pass 
through  an  agony  of  indescribable  terror.* 

"  Shall  we  use  ether  or  chloroform,  in  the  aged  and  infirm  ? 
Here  we  are  dealing  with  organs  as  delicate,  as  fragile  glass- 
ware. The  heart  is  tottering  in  its  action,  and  the  brain  is  fed 
by  vessels  too  brittle  for  any  overstrain.  Shall  we  select  the 
milder  anaesthetic,  the  safer  for  the  heart,  but  which  usually 
excites  such  violent  struggling,  and  such  tumult  in  the  circu- 
lation, as  to  endanger  the  cerebral  vessels  by  rupture,  and 
which  causes  subsequent  dangers  so  serious  in  infirm  people  ? 
Or  shall  we  select  chloroform,  which  obviates  all  the  objections 
to  ether,  but  which  unquestionably,  in  these  subjects,  acts  on 
the  cardiac  and  respiratory  nervous  apparatus  with  increased 
energy?  The  condition  of  the  organs  endangered  in  individ- 
ual cases,  should  decide  the  choice.  In  infirm  subjects,  more 
especially,  anaesthesia  should  be  begun  with  ether,  when  not 
contraindicated,  and  so  continued  in  those  who  take  it  well. 
If  there  be  much  struggling  and  resistance,  or  much  increased 
bronchial  secretion,  or  other  evidences  of  the  injurious  action 
of  ether,  then  chloroform  should  be  substituted.  In  our  expe- 
rience, after  the  first  effect  of  ether,  chloroform  has  proved  the 

*  See  our  article  on  "  Chloroform  as  an  Anesthetic  in  Children  " 


520  ARTIFICIAL   ANAESTHESIA. 

preferable  agent  in  most  cases  of  aged  and  infirm  subjects, 
save  those  whose  hearts  are  very  weak  and  irregular. 

"Shall  we  use  ether  or  chloroform  in  cases  which  may  be 
seriously  complicated  by  nausea  and  vomiting,  as  in  abdominal, 
and  gynecological  surgery,  and  the  surgery  of  the  cerebrum  ? 
The  danger  of  suffocation  by  vomited  matter,  especially  in 
etherization,  should  never  be  lightly  regarded,  nor  the  ill- 
effects  of  persistent  nausea,  and  retching  on  the  healing  of  im- 
portant wounds.  Chloroform,  less  frequently  than  ether,  causes 
vomiting,  and  in  emergencies  requiring  general  anaesthesia 
before  the  digestion  of  a  meal,  is  the  preferable  agent.  In- 
deed, in  all  cases  where  obstinate  retching  after  surgical  opera- 
tion might  endanger  life,  chloroform  is  preferable. 

"As  a  measure  to  prevent  nausea  and  vomiting  under  anaes- 
thesia, we  wish  to  lay  stress  on  the  importance  of  administer- 
ing the  ansesthetic  gradually,  and  maintaining  the  anaesthesia 
in  a  uniform  degree.  Any  surprise  to  the  centres,  or  sudden 
alteration  of  their  molecular  or  nutritive  changes,  may  cause 
nausea.  An  hypodermatic  injection  of  the  sulphate  of  mor- 
phia occasionally,  has  this  effect.  So,  anaesthetics,  or  other 
agents  acting  similarly,  when  administered  interruptedly,  act 
unevenly  on  the  centres,  and  by  such  repeated  surprises  cause 
nausea.     They  act  like  a  rough  sea. 

"  Chloroform  and  ether,  therefore,  have  their  respective 
fields  of  usefulness,  in  which  they  are  equally  serviceable. 
They  are  equally  dangerous  when  given  in  the  face  of  their 
contraindications.  Not  until  medical  men  learn  to  discrimi- 
nate properly  in  their  choice  of  these  anaesthetics,  and  recog- 
nize the  fact  that  the  dangers  of  general  anaesthesia,  depend  as 
much  on  the  method  of  administration,  as  on  the  toxical  prop- 
erty of  the  agent  employed,  will  the  risk  of  fatal  accidents 
ever  be  reduced  to  the  minimum." 

Our  only  observation  on  this  valuable  paper,  is  not  "which," 
but  both  in  the  proper  cases. 


CHOICE  OF    ANESTHETICS.  521 


CONCLUSION. 

On  tlie  Choice  of  AiiaE5Stlietics,  and  the  Impoi^tance 
of  Great  Caution,  in  Producing  Anaesthesia. 

For  all  minor  operations  in  surgery,  at  the  house  of  the  pa- 
tient or  in  private  oiEce  (when  the  cost  of  the  anaesthetic  is  of 
no  consequence,  and  where  disagreeable  odor  is  to  be  avoided), 
nothing  has  yielded  us  such  satisfactory  results,  as  cocaine  or 
bromide  of  ether.  For  all  dental  operations  (except  tedious 
and  protracted  dissections  on  the  mouth),  the  safest  ansesthetic 
is  nitrous  oxide  gas,  and  ether  where  many  teeth  are  to  be  ex- 
tracted, which,  in  its  results,  is  exhilarating  and  most  satisfac- 
tory, and  with  but  little  effort  produces  complete  insensibility 
to  pain,  and  is  most  rapidly  eliminated  from  the  system.  For 
dangerous  and  protracted  operations,  the  agent  which  has  been 
employed  in  this  city,  and  in  the  United  States,  is  the  pure 
ether ;  the  proofs  of  its  comparative  safety  are  full  and  com- 
plete. Chloroform,  as  an  ansesthetic,  has  a  long  and  painful 
record  of  valuable  lives  lost  from  the  time  of  its  introduction 
to  the  present  day,  so  that  no  one  is  justified  in  using  it,  unless 
the  ordinary  agents  specified  above  fail  him,  or  unless  he  has 
to  employ  the  actual  cautery ;  even  with  little  children,  it  is 
not  absolutely  safe,  and  a  reference  to  the  body  of  this  work, 
and  tables,  will  show  that  numerous  deaths,  follow  its  use. 

Every  combination  of  chloroform,  its  various  modes  of  ad- 
ministration in  both  large  and  small  quantities,  and  mixed  with 
other  agents,  have  been  experimented  with,  but  those  who  have 
employed  it  most,  have,  when  its  positive  fatal  action  is  seen, 
has  had  at  last  to  resort  to  ether,  or  nitrous  oxide  and  ether. 

Great  care  is  to  be  exercised  in  the  quantity  employed  of 
chloroform,  bromide  of  ethyl,  and  cocaine,  and  it  is  prudent  to 
refuse  them  to  aged,  anaemic,  feeble,  or  highly  nervous  persons. 


INDEX. 


ACETIC  Ether,  265  ;  anaastlietic  prop- 
erties, experiments  by  Dr.  H.  C. 
Wood,  265  ;  A.-C.-E.  mixture,  acci- 
dents with,  493  ;  A.-B.-C.  mixture, 
493.  Acetic  aldehyde,  284,  285. 

Acid,  Carbolic,  29,  112 ;  antidotes  to 
poisoning  from,  113  ;  as  a  local  an- 
aesthetic, 29, 112  ;  death  from,  114  ; 
fatality,  in  a  Belfast  hospital,  114 ; 
in  arresting  putrefaction,  112 ;  in 
fistula,  113  ;  intoxication  from  its 
local  application,  114  ;  in  ulcers  and 
hemorrhoids,  113  ;  injections  in  hy- 
drocele, 113  ;  ofiBcinal  preparations, 
112  ;  pure  carbolic  acid  united  with 
cocaine,  72  ;  pure  and  impure  car- 
bolic acid,  112 ;  therapeutic  proper- 
ties, 113. 

Acid,  Carbonic,  as  a  local  anaesthetic,  29  ; 
introduction  by  Prof.  Percival  to 
relieve  pain,  29  ;  recommended  by 
Prof.  Dewees  in  cancer  of  uterus 
and  rectum,  29. 

Action,  irregular,  chloroform,  337  ;  co- 
caine, 29;  ether,  221. 

Acupressure,  29. 

Administration  of  chloroform,  374 ;  co- 
caine, 41 ;  ether,  222  ;  nitrous  ox- 
ide, 137. 

After-treatment  of  ansesthetized  patients 
from  alcohol,  216  ;  cocaine,  48 ; 
chloroform,  374  ;  ether,  226. 

Agnew,  D.  H.,  M.D.,  case  of  death  from 
ether,  243. 

Albumon,  after  the  administration  of 
chloroform,  499. 

Albuminuria,  dangers  of  administration 
of  ether  in,  237. 


Alcohols,  different  kinds,  214 ;  as  a 
chemical  agent,  214  ;  as  a  systemic 
anjesthetic,  215  ;  absolute,  214 ;  as 
found  in  whiskey,  brandy  and  wine, 
215  ;  as  an  anaesthetic,  215 ;  alleged 
dangers  which  accompany  inhala- 
tion of  alcohol  or  its  mixtures,  215  ; 
poisoning  from,  216;  of  U.  S.  Phar- 
macopoeia, 214 ;  observations  of 
Drs.  Link,  Miiller,  and  the  late  Val- 
entine Mott,  217,  218  ;  strychnine 
in  alcoholism,  219 ;  toxicological  ef- 
fects and  treatment  of,  219. 

Aldehyde,  284. 

Allis,  Dr.  0.  H.,  ether  inhaler,  339 ; 
improved  form,  346  ;  experiments  at 
Howard  Hflspital,  343. 

Amory,  Dr.,  Boston,  experiments  by,  159. 

Amyl  Nitrite,  499  ;  antidote  to  cocaine, 
499,  500  ;  in  anaemia  of  brain,  48  ; 
failure  of,  426 ;  physiological  and 
therapeutic  effects  of,  499-502. 

Amylene,  as  an  anaesthetic,  279  ;  dan- 
gers from,  279;  Dr.  Snow,  experi- 
ments of,  279. 

Ansemia,  use  of  amyl  nitrite  in,  48. 

An£esthe8ia,_artificial,  by  alcohol,  216 ;  by 
cocaine,  27 ;  chloroform,  374  ;  chlo- 
roform and  oxygen,  474  ;  discovery 
of,  18,  19  ;  by  ether,  221-223 ;  his- 
tory of,  17-22  ;  local,  57  ;  mandra- 
gora,  17  ;  methylene  bichloride,  267- 
273  ;  nitrogen  gas,  145  ;  nitrous  ox- 
ide, 157,  158 ;  opium,  18 ;  oxygen 
gas,  202;  prolonged  chloroform, 
462, 490  ;  produced  by  draining  blood 
from  the  head,  359  ;  true  value  of, 
25  ;  new  method  for  producing,  506. 

523 


624 


INDEX. 


Anaesthetics,  action  on  the  brain  and 
nervous  systeni,  IGl  ;  effects  of  Buil- 
den  reductign  of  temperature,  240  ; 
in  dental  surgery,  72;  in  the  blood, 
145  ;  local,  28  ;  list  of  general,  tables 
of  the  ratio  of  deaths  from,  435,  436; 
legal  reBponsibility  in,  443-446;  list 
of  general,  505  ;  mixed,  201  ;  oxy- 
gen gas  as  an,  2U2 ;  proprietai-y, 
201  ;  table  of  deaths  from  various, 
436  ;  theories  of  the  manner  in 
which  they  produce  their  effects,  26  ; 
the  true  value  of,  25. 

Analgestics,  nutipyrin,  115  ;  iodoform, 
274  ;  rapid  breathing,  29. 

Angina,  diphtheritic  or  pseudo-mem- 
branous croup,  258. 

Angina  pectoris,  4!)9-501  ;  treatment  by 
nitrite  of  amy],  501. 

Anrep,  Von,  37. 

Antagonism  of  chloroform,  cocaine  and 
ether,  48. 

Antidote  to  poisoning  with  cocaine,  48  ; 
carbolic  acid,  113,  114  ;  chloroform, 
459;  chloral  hydrate,  44;  strych- 
nine, 219. 

Antifebrin,  116. 

Antipyrin,  115,  116;  as  an  anipstbetic, 
117  ;  in  dysmenorrhcea,  117  ;  a  local 
anjEsthetic,  117. 

Aphonia,  or  temporary  loss  of  voice, 
treatment  by  ether,  258 ;  nitrous 
oxide,  1S6. 

Asphyxia,  156 ;  from  chloroform,  210, 
378,  434  ;  ether,  221  ;  formic  ether, 
265  ;  nitrous  oxide,  15G  ;  Keid's  ex- 
periments on,  1S2 ;  artiticial  re- 
spiration in  chloroform  narcosis, 
389. 

Asthma,  bronchial,  212 ;  treatment  by 
chloroform,  ether,  257  ;  nitrite  of 
amyl,  500;  nitrous  oxide  gas,  186, 
191,  192  ;  oxygen,  212. 

Atlee  (the  late),  Washington  L.,  his 
success  and  o])inion  in  operations 
with  mixed  anaesthetics,  468,  4(i9. 

Atropia,  with  ether  or  chloroform,  231, 
381. 

Aubean,  Dr.,  of  Paris,  experiments  with 
solution  of  cocaine  in  dentistry,  72. 


KARTHOLOW,  PROF.,  on  dangerotiB 
symptoms  from  ether,  236. 

Bauuschiedt's  instrument  for  perforat- 
ing the  skin  with  needles,  29. 

Beddoes,  Thomas,  effects  of  gases,  16 ; 
pneumatic  method,  15. 

Bernard,  Claude,  experiments  with 
chloroform  and  morphia,  470;  co- 
caine antagonistic  to  nitrite  of  auiyl, 
48. 

Bert,  M.  Paul,  nitrous  oxide  and  oxy- 
gen, 93. 

Bichloride  of  ethylene,  276, 277  ;  experi- 
ments, 277. 

Bichloride  of  methylene,  267  ;  discoTery 
and  introduction  of,  267 ;  use  by 
Eichardson.  Jones,  and  others,  267  ; 
deaths  from,  27(l,  271. 

Blgelow,  Br.  H.  I.,  on  rhigolene,  91. 

Bilroth,  of  Vienna,  use  of  mixed  anses- 
thetics,  438. 

Bird,  Thomas,  experiments  with  bichlo- 
ride of  ethjdene,  276. 

Blood,  action  of  ana^thetics  npon,  153. 

Bonwill's  method  of  anaisthesia,  29. 

Boston  monument  to  commemorate  the 
discovery  of  anaesthesia  by  ether.  26. 

Brackett,  Dr.  C  A.,  a  prolonged  anes- 
thesia from  nitrous  oxide,  136. 

Brandy,  use  of,  as  an  anaesthetic,  in 
dijihtheria,  218,  219. 

British  Medical  Association's  Beport  on 
Anreslhftics,  276. 

Briglit's  disease,  cases  of  death  from, 
after  ether,  237. 

Bromide  of  ethyl,  293  ;  chemical  prop- 
erties, 293,  294  ;  deaths  from,  2B5  ; 
physiological  action  of,  298 ;  ex- 
periments on  animal  Si  and  men,  308, 
309;  mode  of  employment,  309; 
precautions  in  regard  to  its  use,  308, 
309 ;  table  of  composition,  325  ; 
value  in  dental  operations,  322. 

Bromide  of  potassium,  a  local  anesthetic, 
l(i9,  110. 

Bromoform,  properties  of,  275  ;  expeii- 
ments  of  Prof.  Iteichert  in  relation 
to,  275. 

Bronchial  irritation  from  ether  as  an 
auiesthetic,  510. 


INDEX. 


525 


Bronchitis,  treatment  by  ether,  258. 

Brucine,  9G. 

Brunton,  Lauder,  results  of  incomplete 
anajsthesia,  422,  423,  432. 

Burns,  intense  pain  relieved  by  cocaine, 
79. 

Butyl  chloride,  277. 

Buxton,  Dudley,  incomplete  anassthesia, 
action  of  cocaine  on  heart  of  frog, 
39  ;  administering  nitrous  oxide  to 
children,  177  ;  the  physiological  ac- 
tion of  nitrous  oxide,  154-169;  im- 
purities in  ether,  221  ;  on  Sir  Spen- 
cer Wells'  methylene,  272 ;  on 
Clover's  inhaler  for  nitrous  oxide 
and  ether,  359  ;  on  stages  of  chloro- 
form, 374. 

CAFFEINA,  98. 

Canadol,  98. 

Carbon,  dichloride  of,  275  ;  tetrachlo- 
ride of,  275  ;  physiological  action  of, 
29. 

Carter,  B.,  of  London,  on  the  use  of 
mixed  anaesthetics  in  operations  on 
the  eye,  472,  473. 

Catarrh,  cocaine  in  treatment  of,  79. 

Chilblain,  cocaine  in  treatment  of,  78. 

Chisbolm,  Dr.  Julian  J.,  a  very  valuable 
lesson  for  those  whe  use  anassthetlcs 
on  children,  414-418. 

Chloral  hydrate,  111,  112 ;  as  a  local  an- 
aesthetic, 111 ;  associated  with  cam- 
phor, 111 ;  in  cocaine  habit,  44. 

Chloric  ether,  275. 

Chloroform,  administration  of,  373-376  ; 
antidotes  for  poisoning  by,  459  ;  an- 
aesthesia for  children,  399;  com- 
ments upon  deaths  from,  432-435  ; 
deaths  from,  402,  410,  415.  423; 
dangers  of  administering  without 
an  attendant,  457,  458  ;  dangerous 
symptoms,  385  ;  discovery  of,  25,  365  ; 
during  sleep,  administration  of,  446, 
447  ;  erotic  hallucinations  from,  457, 
458  ;  employed  first  by  Prof.  Simp- 
son, 25  ;  fatty  degeneration  from, 
462,  490 ;  irregular  action  of,  385  ; 
impure,  366,  367  ;  influence  on  the 
circulation,  respiration  and  nervous. 


system,  385;  mode  of  administering 
chloroform  in  France,  439-441  ;  nar- 
cosis, 379  ;  ordinary  method  of  pre- 
paring, 365  ;  perils  of  dental  opera- 
tions in  employment  of,  430-432 ; 
physiological  and  anaesthetic  action, 
369;  prevention  of  excessive  vomit- 
ing, 405  ;  purified,  367 ;  rules  for 
administration,  374 ;  stages  of  ad- 
ministration, 374  ;  tests,  368  ;  toxi- 
cological  effects,  377,  378  ;  when 
used  with  safety,  439. 

Cholera,  treatment  with  ether,  camphor, 
etc.,  256. 

Chorea,  hand  spray  of  ether,  258. 

Clark,  Sir  Andrew,  cocaine  in  hay  fever, 
80. 

Coca,  leaves,  plants,  preparations,  30 ; 
nse  of  by  Peruvians,  30-32. 

Coca,  wine  of,  from  leaves  and  cocaine, 
31. 

Cocaine,  chemical  properties  of,  33  ; 
deaths  from,  in  asthma,  82 ;  in 
affections  of  the  stomach,  49-55,  75  ; 
in  burns,  78 ;  in  boulimie  or  insa- 
tiable hunger,  77  ;  in  cracked  nip- 
ples, 79  ;  Crothers,  Dr.  T.  D.,  co- 
caine habit,  treatment,  44,  45 ;  in 
diseases  of  the  eye  and  ear,  83-89  ; 
in  dental  practice,  75  ;  in  general 
surgery,  60  ;  in  operations  on  the 
eye  hypodermically,  39  ;  in  minor 
surgery  with  special  rules,  62  ;  in 
lavage  or  gavage,  77  ;  in  skin  dis- 
eases, 78 ;  insuffiation  and  inhala- 
tion, 82  ;  in  uncontrollable  vomit- 
ing, 76  ;  keratitis  from  strong  solu- 
tions, 83  ;  KoUer,  the  true  discoverer 
of  its  action  on  the  eye,  31-33  ;  mix- 
ture for  cough  and  chronic  pharyn- 
gitis, 81  ;  Mosso,  of  "  Turin,"  38  ; 
named  by  Niemann,  33  ;  Niemann, 
Wohler  and  Losson  on  chemical 
nature,  34  ;  operation  on  the  eye  by 
Dr.  Aubeau,  M.  Telschow  and  Prof. 
Viau,  72 ;  panophthalmitis  ascribed 
to  it,  83  ;  paroxysmal  sneezing,  82  ; 
physiological  experiments,  36  ;  phy- 
siological action  on  dogs,  by  Beich- 
ert.  Hare  and  Turnbull,  of  Fhlla- 


526 


INDEX. 


delphia,  36-39  ;  physical  characters, 
33-35  ;  solutions,  to  prevent  fungi 
forming  in  them,  41 ;  source  of  and 
quantity  employed,  35  ;  teste,  35  ; 
treatment  of  chilblain,  78;  tetanus 
treated  by,  with  morphia,  77 ;  toxic 
effects  of,  49  ;  tracings  with  the 
frog's  heart,  40  ;  urethral  anaesthe- 
sia and  surgical  use,  64-G6 ;  Von 
Anrep,  37  ;  whooping  cough  treated 
by,  with  resorcin,  81. 

Cold  in  the  head,  cocaine  in  treatment 
of,  79,  80. 

Colton,  Dr.,  on  the  safety  in  disease  of  ni- 
trous oxide,  188  ;  reintroduction,  33. 

Conclusions  as  to  the  choice  of  an  antes- 
thetic,  52. 

Corning,  Dr.  J.,  his  mode  of  local  anaes- 
thesia, 29, 359. 

Coryza,  cocaine  in,  ether  comp.,  treat- 
ment of,  70,  80. 

DA  COSTA,  DB.,  cocaine  in  rose  cold  or 

hay  fever,  82. 
Danger    from    chloroform,    385 ;  ether, 

231 ;  nitrous  oxide,  140  ;  incomplete 

anjestheeia,  432  ;  mixed  anaestheticB, 

469,  470. 
Dangers  from  the  use  of  hypnotism,  504. 
Davy,  Sir  Humphry,  experiments  with 

nitrous  oxide,  19,  20. 
Deaths  from  amylene,  279  ;  cocaine,  49- 

60;  chlorofurm,402,  410,  415,  423. 
Degeneration,  fatty,    chloroform,    462, 

490. 
Demarquay,  -views  on  safety  of  oxygen 

gas  by  inhalation,  209. 
Dental  operations,  chloroform  in,  430, 

432;  danger  of  the  upright  posture, 

423 ;  ether  and    nitrous  oxide,   its 

safety  in,  200,  201. 
Diarrhoea,  treatment  by  ether,  camphor, 

250  ;  treated  by  iodoform  and  char- 
coal, 102. 
Dichloride  of  ethidene,  282-284. 
Dioscorides  on  the  use  of  mandragora, 

17. 
Diphtheria,  treatment  of,  by  iodol,  108. 
Dudgeon  on  the  use  of  Indian  hemp,  18. 
Dutch  liquor  as  an  anaesthetic,  276,  277. 


Dysmenorrhoca  antipyrin  in,  117  ;  ether 
in  treatment  of,  :;56. 

EPDEDRINE,  96. 

Epilepsy,  nitrite  of  amyl,  500;  nitrous 
oxide,  192. 

Erichsen,  on  mortality  in  aneesthetics, 
438. 

Erythrophleine,  97. 

Ether,  ethyl,  220  ;  administered  by  in- 
halation, 221-223. 

Ether  or  chloroform,  which  7  508-520  ; 
chemical  reaction,  composition,  and 
manufacture,  220;  cases  in  which  it 
should  be  employed,  519,  621 ;  cases 
in  which  it  should  not  be  employed, 
236;  cone,  towel  for  administralion, 
223  ;  dangerous  symptoms,  231 ; 
deaths  from,  237-216;  D.  E.  B. 
Squibb,  230  ;  fortior,  230 ;  glass  or 
tin  in  preserving,  pure,  227,  228 ; 
impurities,  221  ;  inflammability, 
229  ;  internal  administration,  255- 
259 ;  intoxication  from,  261-264  ; 
local  anfesthetic,  91,  92  ;  manufac- 
ture of,  220 ;  ordinary  method  of 
inhalation,  222;  physiological  ac- 
tion, 223 ;  precautions  to  be  em- 
ployed before  and  after  administer- 
ing ether,  226,  227  ;  pulse  tracings, 
224,  225  ;  sphygmographic  tracings, 

234  ;  spiay,  257,  269  ;  treatment  of, 

235  ;  use  of  and  objections  to,  253  ; 
vivisections,  use  of,  in,  264. 

Etherization  by  rectum,  286 ;  advan- 
tages of,  287  ;  dangers  of,  288 ;  death 
from,  293  ;  discovery  of,  286 ;  Mil- 
ler's apparatus  and  conclusions,  291, 
292. 

Ethidene  chloride,  275  ;  bichloride,  27G- 
277. 

Ethidene  dichloride,  282,  283  ;  chemical 
properties  of,  283  ;  deaths  from,  284  ; 
physiological  characters  and  action, 
282,  283. 

Ethyl  bromide,  293  ;  cases  in  which  it  is 
suitable,  299,  300;  cases  in  which  it 
is  unsuited,  301  ;  chemical  prop- 
erties, 293  ;  Chisholm's  cases,  302, 
310;  deaths  from,  296,  297;  discoverer 


INDEX. 


527 


of,  294 ;  physical  characters,  298 ;  un- 
pleasant effects  due  to  impurities, 
307 ;  use  of,  in  obstetrics,  312  ;  Wat- 
son's experiments,  327. 

Ethylene  bromide,  274. 

Ethylene  ethylate,  278. 

Ethyl  nitrate,  288. 

Eucalyptus  oil,  local  ansesthetic,  91. 

Evans,  Dr.,  Paris,  reintroductiou  of  ni- 
trous oxide  into  England,  21. 

FISTULA,  cocaine  in  treatment  of,  65. 
Flatulent  dyspepsia,  carbolic  acid    in, 

113. 
Flushings  of  heat,  nitrite  of  amyl  in, 

601. 
Formic  ether  as  an  ansesthetic,  266. 
Freezing  the  skin  by  chloride  of  methyl, 

91 ;  ether,  90  ;   ice,  27  ;   rhigolene, 

91 ;  salt,  snow,  etc.,  27. 

GAEDEKE,  discovery  of  cocaine  by, 
33. 

Galvanism  in  chloroform  narcosis,  379' 
496 ;  ether,  235. 

Gangrene  following  use  of  cocaine,  402. 

Gasoline,  local  anaesthetic,  91. 

Gasometers  for  nitrous  oxide,  120,  129, 
135. 

Gastritis,  produced  by  poisoning,  treated 
by  cocaine,  75. 

Geisel's,  Dr.,  test  for  cocaine,  35. 

Glottis,  spasm  from  cocaine,  ether  in, 
48 ;  ether,  222,  387  ;  chloroform, 
death  from,  254. 

Gouorrhoeal  ophthalmia,  treatment  by  co- 
caine, 85. 

Goodell,  Dr.  Wm.,  experience  in  admin- 
istering ether,  345. 

Goodwillie,  Dr.,  surgical  operations  un- 
der nitrous  oxide,  136. 

Gout,  treatment  by  ether,  255. 

Gray,  Dr.,  on  oxygen  gas,  302. 

Guilford,  Dr.,  ill  effects  reported  of 
nitrous  oxide,  173  ;  his  own  expe- 
rience of  nitrous  oxide,  173. 

Guthrie,  Mr.  Samuel,  discover  of  chloro- 
form, 365. 

HA3IILT0N,  DR.  A.  M'LANE,  thera- 
peutics of  nitrous  oxide,  186. 


Hammond,  Dr.,  on  the  use  of  large 
doses  of  cocaine,  42  ;  deaths  from 
chloroform,  410. 

Hare,  Dr.  Hobart  A.,  experiments  with 
cocaine,  37 ;  use  of  ether  in  em- 
barrassed respiration,  226 ;  and 
Martin  on  arrested  respiration  in 
anesthesia,  387  ;  injury  to  phrenic 
nerve,  396. 

Hay  fever,  cocaine  in  treatment  of,  80. 

Headache,  antipyrin  in,  116  ;  nitrite  of 
amyl  in,  502. 

Heart,  influence  of  chloroform  on,  378  ; 
influence  of  ether  on,  378. 

Helleborine,  98. 

Hemp,  Indian,  use  of,  as  an  anaesthetic, 
18. 

Hoarseness,  compound  spirits  of  ether, 
257. 

Homatropine,  95. 

Howard,  Dr.,  of  London,  on  raising  the 
epiglottis,  387. 

Hyderabad  Commission  Report,  by  Dr. 
Lawrie,  378. 

Hydrastis  canadensis,  94. 

Hydrate  of  chloral.  111 ;  as  a  local  an- 
aesthetic, 111 ;  also  with  camphor, 
111. 

Hydriodic  ether  as  an  ansesthetic,  266, 
273. 

Hydrobromic  ether  (see  ethyl  bromide), 
293. 

Hygrine,  impurities  of  cocaine,  34. 

Hypnotism,  602  ;  therapeutic,  503. 

Hypnotics  or  soporifics,  504,  505. 

Hypodermic  injection  of  cocaine,  41 ; 
atropia,  381,  408. 

Hysteria,  ether  in  combination  in,  256  ; 
nitrous  oxide  in,  190, 191, 

IODOFORM,  98-104. 

lodol,  104-109. 

Inhalers,  AUis'  Ether,  339 ;  Angrove's 
Ether,  350  ;  advantages  and  disad- 
vantages, 333  ;  Buxton  modification, 
141 ;  Clover's  Small  Portable  Ap- 
paratus, 361,  364  ;  Clover's  Chloro- 
form, 371 ;  Ether,  3C4  ;  Ether  and 
Nitrous  Oxide,  359-361  ;  cone  in- 
haler, 333  ;  Cheatham's  Ether,  337 ; 


528 


INDEX. 


Codmnn  &  Shurtleff's,  354-357; 
Dr.  Thomas'  Nitrous  Oxide,  123; 
Esmiirch's  Chloroform,  372  ;  Ileum's 
Ether,  336  ;  Hnwksley's  Ether,  335  ; 
Junker's,  improved  hy  Buxton,  441, 
442;  modification  of  the  cono,  by 
Dr.  Lento,  334,  338  ;  modification  of 
cone  and  experiments,  by  Morgan, 
348;  Muller,  ether,  with  experi- 
ments, 357  ;  Nitrous  Oxide,  Chloro- 
form and  Ether,  of  Lewis,  142  ;  Ni- 
trous Oxide  and  Ether,  Long's,  201  ; 
Nitrous  Oxide  and  Ether,  354-357 ; 
Ormsby's  Ether,  334  ;  Parl^inson'fl 
Improved,  351-354;  Richardson's, 
319  ;  S.  S.  White  &  Co.'s,  124  ;  Skin- 
ner's Chlorofonn,  372. 

Inquiry  and  Report  of  the  Medico-Chi- 
rurgical  Society  of  London,  232. 

Insanity  from  anesthetics,  507. 

Insomnia,  187  ;  hypnotics  in,  504. 

Intermittent  fever,  nitrite  of  aniyl  in, 
502  ;  quinine  in,  115. 

Iodide  of  ethyl,  273  ;  of  methyl,  279. 

Irregular  action  of  cocaine,  49  ;  chloro- 
form, 380  ;  ether,  22G  ;  ethyl  brom- 
ide, IJOI. 

Irritation  treated  by  cocaine,  78. 

JACKSON,  hint  to  Morton,  23  ;  slight 
experience  of  ether,  23 ;  death 
of,  24. 

Jolyet  and  Blanche's  experiments  with 
protoxide  of  nitrogen,  155,  15li. 

KEYSER,  DR.  T.D.,  treatment  of  fissure 
of  anus  with  cocaine,  G5  ;  letter  on 
solution  of  cocaine  in  the  eye,  83. 

Kidd,  labor,  the  use  of  chloroform  in, 
474-490. 

Kidney  disease,  Emmet  on  danger  of 
administering  ansesthetics  in,  29G ; 
ether  not  to  bo  employed  in,  237. 

Kinlock,  Dr.  R.  A.,  on  puncture  of  the 
heart  in  fatal  symptoms  from  chlo- 
roform, 384. 

Roller's  experiments  on  the  eye,  39. 

KoUer,  the  discoverer  of  the  anaesthetic 
powers  of  cocaine,  41. 


Kolomnin,  case  of  death  from  cocaine,  49. 

LARYNGEAL  tuberculosis,  cocaine  in, 

80. 
Laryngeal  spasm,  caused  by  chloroform, 

378  ;  ether,  222. 
Laughing  giis  (see  nitrous  oxide). 
Levis,  Dr.,  his  case  of  death  from  bro- 
mide of  etliyl,  295,  297  ;    operation 
fur  hydrocele,  05  ;     the  bromide  of 
ethyl  used  in  his  fatal  case,  321. 
Liebreich,     M.    Oscar,    on    substances 
which  cause  local  anajsthesia,  28, 
275,  276. 
Liniment,  chloroform  and  camphor,  111. 
Link,  Dr.,  on  alcohol  as  an  ana;stlictic, 

216. 
Lister,  a  repetition  of  Bert's  experiments, 

371. 
Local  an.-csthesia  and  anaisthetics,  279  ; 
antipyrin,  115 ;  antifebrin,  115 ; 
apomorphine,  97  ;  bromide  of  ethyl, 
109  ;  brucine,  96  ;  bromide  of  potas- 
sium, 110  ;  cocaine,  41 ;  caffeine, 
98 ;  canadol,  98  ;  carbolic  acid,  112  ; 
carbonic  acid,  29  ;  chloral  and  cam- 
phor, 111  ;  chloroform,  27  ;  ephe- 
drine,  95 ;  ether,  81 ;  eucalyptus, 
91  ;  erythrophleine,  97  ;  helleborine, 
98 ;  homatropine,  95,  96  ;  hydras- 
tine,  94;  iodoform,  98-104;  iodol, 
101-109;  iodide  of  ethyl,  110;  le- 
wenin,  96 ;  menthol,  98 ;  methyl 
and  its  chloride,  93;  naphthalin, 
112;  quinine,  115;  rhigolene,  92; 
theiue,  98. 
Local  anoesthesia  by  the  aid  of  cocaine 
and  plienic  acid  mixed,  72-75  ;  ex- 
periments by  Prevost,  on  the  brain 
of  the  frog,  27  ;  list  of,  91. 
Long,   experiments  with   ether,  death, 

etc.,  24,  25  ;  statue  to,  25. 
Louget,  on  narcosis  from  ether,  233,  234. 
Lyman,  Dr.  Henry,  dangers  from  anses- 
thetics,  298  ;  sphygmographic  trac- 
ings, 332. 
MaoEWEN,  the  pupil   in   its    sympto- 

mological  aspects,  373. 
Mandragura  wine,  13;  references  to,  13  ; 
Antony  and  Cleopatra,  14;   Dr.  B. 


INDEX. 


529 


W.  Richardson  on,  13  ;  Dioscorides, 
13  ;  Lucius  Apuleius,  13. 

Mandrake,  13 ;  wine  of,  13. 

Mattison,  Dr.  J.  B.,  of  Brooklyn,  on 
cases  of  cocaine  toxsemia,  47. 

Ma-yo,  in  China,  14;  Dr.  Dudgeon,  of 
Pekin,  on,  14. 

Mays,  Dr.,  on  brucine,  96. 

McGuire,  Dr.  Hunter,  on  chloroform  ad- 
ministration, 406 ;  his  cases  of  death 
from,  426  ;  number  of  cases  in  which 
chloroform  was  successfully  used  by 
him,  406-409. 

McQuillen,  the  late  Professor,  experi- 
ments by,  action  of  ansesthetics  on 
the  blood,  etc.,  146-148. 

Medico-legal  relations  of  anesthetics, 
443-446. 

Menthol,  918. 

Mesmerism,  anaesthetic  effects  of,  502. 

Methyl,  action  of,  93  ;  chloride,  as  an 
anaesthetic,  93;  chemical  proper- 
ties, 93. 

Methylene  bichloride,  267  ;  as  an  an- 
esthetic, 267  ;  discovery  of,  267. 

Methylene,  Dr.  Kichardson  on,  266-268  ; 
death  rate  of,  270-272;  Regnault 
and  Vjllejeau  on,  272  ;  Sir  Spencer 
Wells  on,  267-269. 

Methylic  ether,  266. 

Methyl  iodide,  279. 

Miller,  Dr.  D.  H.,  on  alcohol  as  an  an- 
ajsthetic,  217. 

Miller,  Dr.  John  S.,  use  of  ether  per 
rectum,  291. 

Mixed  ansesthetics,  200,  201,  462,  470. 

Mixtures  of  chloroform,  ether  and  al- 
cohol, 462-470. 

Montgomery,  Dr.  B.  B.,  bromide  of 
ethyl  as  an  anaesthetic  in  labor, 
312-321. 

Morphia  in  cocaine  poisoning,  48. 

Morphia  with  chloroform,  380,  462,  470, 
495. 

Morphia  with  ether,  496 ;  as  a  hyp- 
notic, 505. 

Mortality  statistics,  tables  of,  chloro- 
form, ether,  nitrous  oxide,  etc., 
435,  436. 

Morton,  crowning  result  with  ether,  23. 


Mosso,  of  Turin,  on  increase  of  bodily 
temperature  by  cocaine,  37. 

Miiller,  Dr.  A.  F.,  rapid  anaesthoaia  by 
ether,  357. 

NANCREDE,  DR.,  elevating  the  jaw  ; 
dangerous  symptoms  from  ether, 
235. 

Naphthalin,  112. 

N61aton's  experiments  with  chloro- 
form, 235,  403  ;  failure  of,  426. 

Nervous  headache,  116,  502. 

Neuralgia,  chloral  hydrate  and  cam- 
phor in,  111 ;  nitrous  oxide  in,  190. 

Niemann,  experiments  with  cocaine,  33, 
34. 

Nitrite  of  amyl  in  angina  pectoris,  499- 
502 ;  in  asthma,  50u ;  antidote  to 
cocaine,  48;  impurities,  how  re- 
moved, 500. 

Nitrous  oxide,  as  an  anaesthetic,  .137 ; 
action  of,  143-171 ;  averages  in  a 
large  number  of  administrations, 
139  ;  after-effects  and  experiments 
by  J.  D.  Thomas,  153, 172 ;  author's 
conclusions,  170 ;  Buxton's  experi- 
ments, 154,  156,  160-169;  Clover's 
inhaler  for  ether  and,  140-142 ; 
Clover  and  Lewis,  of  Buffalo,  and 
Long  inhaler,  141,  142 ;  Sir  Hum- 
phrey Davy,  use  of  by,  19,  20 ; 
deaths  from  inhalation,  178-185; 
Dr.  Silk  on  the  administration  of 
ether  and,  199,  200  ;  difBculties  and 
dangers  of,  140,  176 ;  Dr.  Evans,  of 
Paris,  introduction  of  Jiquid  gas 
into  England,  21 ;  gasometer  with 
inhaler,  120;  nickel-plated,  128, 
129 ;  hints  by  Clover  on  ether  and, 
193-198;  in  dental  practice,  176; 
in  prolonged  surgical  operations, 
136 ;  introduction  by  Wells,  20 ;  in- 
halers, 123-126;  Jolyet  and  Blanche 
on,  155;  Johnson's  gas-table,  126- 
128 ;  liquid,  126  ;  mixtures  for  in- 
halation, 200,  201  ;  McQuillen,  ex- 
periments with,  146 ;  mode  of  prep- 
aration, 119-123 ;  number  of  ad- 
ministrations, 172 ;  oxygen  as  an 
anaesthetic     in     labor     with,    193 ; 


530 


INDEX. 


proper  nioihod  for  administering, 
137,  138,  177  ;  pliysic"!  properties' 
143-171  ;  Bpcctrogoopo  iinii  its  re- 
lations to,  150-154;  spliyginograph- 
ic  triiciugs  from  patients  under  the 
influence  of,  138,  139;  therapeviti- 
cal  application  of,  185,  193;  the 
safety  of,  172. 

Nizam  Government  report  on  cliloro- 
forni  by  Dr.  Lawrie,  878. 

Nunnelly,  Mr.,  experimenta  with  anaes- 
thetics, 294. 

OBSTETRICAL  SOCIETY  of  Pennsyl- 
vania, discussion  on  hydrobromic 
ether,  321. 

Olcfiaut  gas,  bromide  of,  274. 

Ophthalmic  surgery,  mixed  aniesthctics 
in.  440^73. 

Ott,  Dr.,  scientific  researches  under  bro- 
mide of  ethyl,  30G. 

Ovariotomy,  4(58,  409. 

Oxide  of  ethyl  ether,  as  an  anrestln'tic, 
220. 

Oxygen  gas  as  an  anaesthetic,  202  ;  as  an 
antidote  to  chloroform,  210;  anti- 
dote to  ether,  212  ;  in  diseases  of  the 
chest,  209 ;  experiments  of  Drs. 
Gray,  Wood,  A.  H.  Smith  with, 
202,  203 ;  mode  of  preparation,  208 

PANCOAST,    death    from     chloroform, 

420-422. 
Paraldehyde,  285. 
Paralysis,  treated  by  nitrous  oxide,  ISO, 

192. 
Parrish,   Dr.  W.   IT.,  on   the  safety    of 

bromide  of  ethyl,  321. 
Pereira,  on  ether,  22,  23 
Phillips'  cocaine  in  obstetrics,  71. 
Photophobia,  treated  by  cocaine,  85. 
Pneumonia  following  etherization,  253, 

254. 
Post  partum  hemorrhage,  ether  in,  257. 
Pouncet,  abandons  use  of  moriihia  with 

chloroform,  498. 
Prevost,  chloroform  applied  directly   to 

•    the  brain  of  the  frog,  27. 
Priestly  and  Scheele,  different  kinds  of 

airs  and  gases,  19. 


Pruritus   vulva,  treatment  by    cocaine, 

79. 
Pupil  in  chloroform,  376. 

QUIMBY,    on  chloroforming     patients 

when  asleep,  455. 
Quinine,   as  an  anaisthetic,   116;  as  an 

antipyretic,  115. 

KANKE  and  Claude  Bernard,  action  of 
chloroform  ou  the  nerve  cells,  277. 

Reeve,  Dr.  J.  C,  cases  of  sudden  death 
under  ether,  237  ;  his  oi)inion  of, 
243  ;  also  bromide  of  ethyl,  303. 

Regnauld  et  Yillejeau,  researches  on 
connnercial  methylene,  272. 

Reichert,  Professor,  experiments  with 
cocaine,  37-39 ;  experiments  with 
bromoform,  275. 

Respiration,  artificial,  by  Sylvester,  386 ; 
arrested  treatment  of,  387  ;  forced, 
386. 

Restlessness  relieved  by  nitrite  of 
amyl,  5C1. 

Resuscitation  from  death  by  chloro- 
form, 382. 

Rhigolene,  as  a  local  anaesthetic,  92,  93. 

Ring,  Dr.  V.  \V.,  personal  experience  in 
the  use  of  cocaine,  45. 

Ringer,  Dr.  Sydney,  on  chlorohydrate 
of  ephedrine,  95  ;  incomplete  anas- 
thesia,  danger  of,  95. 

Roberts,  Dr.  M.  I  ,  cocaine  anaeiithesia 
in  femoral  supra-C(jndyloid  oste- 
otomy, Ci{). 

S.VNSOM,  stimulating  effects  of  alcohol, 
405. 

Schiff,  Professor,  on  the  difference  of 
aiia?sthesia  by  ether  and  chloro- 
form, 2^4,  378,  434. 

Sciatica,  subcutaneous  injections  of 
chloroform  and  ether  in,  257. 

Seasickness,  nitrite  of  amyl  in,  502. 

Sexual  e.xciteiuent  after  the  use  of 
chloroform,  457 ;  ether,  454. 

Silk,  Dr.  I.  Fred.  W.,  remarks  on  re- 
cent deaths  under  chloroform,  418- 
420. 

Simes,  Dr.  J.  Henry,  his  case  of  death 
from  cocaine,  52. 


INDEX. 


531 


Simpson,  Sir  J.  T.,  first  use  of  chloro- 
form, 24  ;  honors  to,  25. 

Sims,  Dr.,  death  from  bromide  of 
ethyl,  296. 

Simg,  Dr.  Marion,  on  chloroform,  382 ; 
ether,  382;  death  from  bromide  of 
ethyl,  296;  method  of  preventing 
death  from  chloroform,  382, 

Skinner's  chloroform  inhaling  appar- 
atus, 372. 

Smith,  Dr.  Andrew  H.,  experiments 
with  oxygen,  203. 

Snow,  amount  of  vapor  which  is  safe  to 
use  369;  deaths  from  chloroform, 
238  ;  vapor  in  the  blood,  370. 

Soporative,  analysis  of  by  Trimble,  324. 

Souberain,  discovery  of  chloroform, 
K65. 

Spectroscope,  its  relation  to  the  action 
of  anaesthesia  on  the  blood,  150- 
153. 

Sponge,  somniferous,  18. 

Squibb's,  Dr.,  quantity  of  cocaine  em- 
ployed, 35 ;  solutions  of  cocaine, 
33;  ether,  229,  230  ;  ether  taking 
fire  from  escaping  vapor,  227-229. 

Symptoms  of  danger  from  chloral,  280 ; 
chloride  of  ethidene,  275. 

Syncope  from  chloroform,  378,  434 ; 
ether,  378  ;  nitrous  oxide,  165, 177. 

TABLE  of  deaths  from  chloroform, 
435,  436 ;  ether,  435,  436  ;  mixed 
anesthetics,  435,  436 ;  ether  amy- 
lene,  435,  4.36 ;  bromide  of  ethyl, 
435,  436. 

Tables  of  ratio  of  deaths  from  the  va- 
rious anaesthetics,  435,  436. 

Tape-worm,  ether  in,  256. 

Taylor  on  criminal  use  of  chloroform 
and  ether,  448. 

Teri-illon  on  bromide  of  ethyl,  306. 

Tetanus,  treated  by  cocaine  and  mor- 
phia, 77  ;  ether  spray,  259. 

Tetrachloride  of  carhon,  275. 

Theine,  98. 

Therapeutic  uses  of  alcohol,  218  ;  car- 
bolic acid,  113  ;  chloral  and  cam- 
phor, 111  ;  cocaine,  75  ;  ether,  255. 

Thomas,  the  late  Dr.  ;  his  brother,  J. 


D.  Thomas,  D.D.S.,  on  the  safety 
of  nitrous  oxide,  172;  number  of 
cases  in  which  he  has  employed  it, 
172. 

Tinnitus  aurium,  treatment  by  nitrite  of 
amyl,  502  ;  bromide  of  ethyl,  301. 

Tschudi  on  the  value  of  coca  leaves  in 
elevated  regions,  32. 

VERTIGO,  nitrite  of  amyl  in,  499. 

Vivisection,  chloroform,  ether,  264,  381  ; 
comparison  of,  with  bromide  of 
ethyl,  mixture  of  atropia,  381. 

Vomiting,  obstinate,  of  pregnancy,  76  ; 
from  chloroform,  405  ;  how  to  pre- 
vent by  cocaine,  76. 

Von  Anrep  on  increase  of  temperature 
of  skin  after  use  of  cocaine,  37. 

WALDIE,  DR.,  chloroform  recom- 
mended by,  to  Professor  Simpson, 
25. 

Warren,  Dr.,  of  Boston,  use  of  ether  in 
a  capital  operation,  administered  by 
Dr.  Morton,  23. 

Warren,  Dr.  John  C,  on  the  use  of 
ether  in  the  agonies  of  death,  260. 

Watson,  Dr.  B.  A.,  experimental  study 
of  anfesthetics,  327. 

Weir,  Dr.  Robert  T.  and  Weeks,  on 
iodoform,  104. 

Wells,  Dr.  Horace,  discoverer  of  mod- 
ern anaesthesia,  20 ;  nitrous  oxidej 
use  of,  20;  monument  to,  21. 

Wells,  Sir  Spencer,  on  bichloride  of 
methylene,  267. 

Whooping-cough,  ether  in,  258,  259 ; 
and  resorcin,  81. 

Wood,  Dr.  Horatio  C,  theory  of  the 
manner  in  which  anaesthetics  pro- 
duce their  effects,  27  ;  treatment  of 
dangerous  symptoms  from  ether, 
235,  236 ;  experiments  on  animals 
with  bromide  of  ethyl,  307. 

Wyeth,  Dr.  John  A.,  the  status  of  co- 
caine in  surgery,  62-65. 

ZAUTCHEVSKY,  DE.  V.  M.,  morbid 
changes  in  acute  and  chronic  pois- 
oning of  dogs  by  cocaine,  56. 


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